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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 ...
Electronic referrals. E-referrals or electronic referrals or electronic consultation is an electronic platform that enables the seamless transfer of patient information from a primary to a secondary treating practitioner's client management system. [1] [2] E-referrals have fast become the best replacement of paper-based referrals, and hold ...
Physician self-referral is a term describing the practice of a physician ordering tests on a patient that are performed by either the referring physician himself or a fellow faculty member from whom he receives financial compensation in return for the referral. Examples of self-referral include an internist performing an EKG, a surgeon ...
Prescriptions may be entered into an electronic medical record system and transmitted electronically to a pharmacy. Alternatively, a prescription may be handwritten on preprinted prescription forms that have been assembled into pads, or printed onto similar forms using a computer printer or even on plain paper, according to the circumstances ...
A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note ( UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.
The Physicians' Desk Reference was first published in 1947 by Medical Economics Inc., a magazine publisher founded by Lansing Chapman. [2] Medical Economics Inc. merged with Reinhold Publishing in 1966 to form Chapman-Reinhold. [3] Litton Industries, which owned the American Book Company, acquired Chapman-Reinhold in 1968. [4]