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Operative Note
An Operative report is a report written in a patient's medical record to document the details of a surgery. The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ... (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. The report is used by healthcare professionals immediately attending the patient’s postoperative recovery, and as the primary basis for reimbursement claims by the surgeon, surgical team, and medical facility. ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Record
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and health care, care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein. Medical records have traditionally been compiled and maintained by health care providers, but advances in online data sto ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Surgery
Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery such as gastric bypass), to reconstruct or alter aesthetics and appearance (cosmetic surgery), or to remove unwanted tissue (biology), tissues (body fat, glands, scars or skin tags) or foreign bodies. The act of performing surgery may be called a surgical procedure or surgical operation, or simply "surgery" or "operation". In this context, the verb "operate" means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments, operating theater, surgical facility or surgical nurse. Most surgical procedures are performed by a pair of operators: a surgeon who is the main operator performing the surgery, and a surgical assistant who provides in-procedure manual assistance during surgery. Modern surgical opera ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical History
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as man ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Physical Examination
In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a medical diagnosis, diagnosis and devise the treatment plan. These data then become part of the medical record. Types Routine The ''routine physical'', also known as ''general medical examination'', ''periodic health evaluation'', ''annual physical'', ''comprehensive medical exam'', ''general health check'', ''preventive health examination'', ''medical check-up'', or simply ''medical'', is a physical examination performed on an asymptomatic patient for medical screening purposes. These are normally performed by a pediatrician, family practice physician, ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Accreditation Association For Ambulatory Health Care
The Accreditation Association for Ambulatory Health Care (AAAHC), founded in 1979, is an American organization which accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations. AAAHC has been granted "deemed status" to certify ambulatory surgery centers for Medicare by the Centers for Medicare and Medicaid Services. In 2009, the AAAHC added the Medical home to the types of organizations that it accredits. It offers on-site surveys for organizations seeking Medical Home accreditation or certification. AAAHC is one of three organizations that accredits office-based surgery practices, the others being the Joint Commission on Accreditation of Healthcare Organizations and the American Association for Accreditation of Ambulatory Surgery Facilities. History The Accredit ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Joint Commission
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements. The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois. History The Joint Commission was formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH). The Joint Commission was renamed The Joint Commission on Accreditation of Hospitals in 1951, but it was not until 1965, when the federal government decided that a hospital meeting Joint Commission accreditation met the Medicare Conditions of Participation, that accreditation had any official impact. However, Sec ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Surgery
Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery such as gastric bypass), to reconstruct or alter aesthetics and appearance (cosmetic surgery), or to remove unwanted tissue (biology), tissues (body fat, glands, scars or skin tags) or foreign bodies. The act of performing surgery may be called a surgical procedure or surgical operation, or simply "surgery" or "operation". In this context, the verb "operate" means to perform surgery. The adjective surgical means pertaining to surgery; e.g. surgical instruments, operating theater, surgical facility or surgical nurse. Most surgical procedures are performed by a pair of operators: a surgeon who is the main operator performing the surgery, and a surgical assistant who provides in-procedure manual assistance during surgery. Modern surgical opera ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
