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The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. [ 8 ] Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. [17]
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
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