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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

  3. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

  4. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...

  5. Occupational licensing - Wikipedia

    en.wikipedia.org/wiki/Occupational_licensing

    To distinguish various forms of regulation, there are three forms of government regulation of occupations: Licensing: Licensing refers to situations in which it is unlawful to carry out a specified range of activities for pay without first having obtained a license. This confirms that the license holder meets prescribed standards of competence.

  6. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    The parts of the mnemonic are: Onset of the event What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain, [2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.

  7. Manual therapy - Wikipedia

    en.wikipedia.org/wiki/Manual_therapy

    Manual therapy, or manipulative therapy, is a treatment primarily used by physical therapists and occupational therapists to treat musculoskeletal pain and disability. It mostly includes kneading and manipulation of muscles, joint mobilization and joint manipulation .

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