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It is available under a BSD-style license. [41] Ginkgo CADx Cross-platform open source DICOM viewer and dicomizer. It is available under the GNU LGPL. [42] Insight Segmentation and Registration Toolkit (ITK) v4.0+ is released under the Apache license. [43] InVesalius 3D medical imaging reconstruction software.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
Armed Forces Health Longitudinal Technology Application. AHLTA is a global Electronic Health Record (EHR) system used by U.S. Department of Defense (DoD). It was implemented at Army, Navy and Air Force Military Treatment Facilities (MTF) around the world between January 2003 and January 2006. It is a services-wide medical and dental information ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice ...
Tools. Front-line health informatics tools (sometimes informally called the " clinical informatics toolbelt ") generally include one of the following: Policies and procedures – Tools used to define organizational standards and how to achieve them. Clinical protocols – Tools used to standardize and automate care in a common clinical scenario.
Records management, also known as records and information management, is an organizational function devoted to the management of information in an organization throughout its life cycle, from the time of creation or receipt to its eventual disposition. This includes identifying, classifying, storing, securing, retrieving, tracking and ...
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