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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [ citation needed ] [ 1 ] The chief complaint is a concise statement describing the symptom , problem, condition , diagnosis , physician -recommended return, or other reason for a medical encounter. [ 2 ]
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Lawrence Leonard Weed (December 26, 1923 – June 3, 2017) [1] was an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records.
To change this template's initial visibility, the |state= parameter may be used: {{Medical records and physical exam | state = collapsed}} will show the template collapsed, i.e. hidden apart from its title bar. {{Medical records and physical exam | state = expanded}} will show the template expanded, i.e. fully visible.
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In medical terms, this is known as a heteroanamnesis, or collateral history, in contrast to a self-reporting anamnesis. Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient.
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