Common Document Types
- SOAP notes — Standardized clinical encounter notes (Subjective, Objective, Assessment, Plan). The primary documentation of each patient visit.
- Treatment plans — Outlined course of care with goals, interventions, and expected outcomes.
- Imaging reports — Radiologist or provider interpretation of X-rays, MRI, CT scans.
- Lab results — Blood work, urinalysis, and other diagnostic test results with reference ranges.
- Operative reports — Detailed description of surgical procedures performed.
- Discharge summaries — Summary provided when a patient leaves a hospital or completes a course of treatment.
- Referral letters — Communication between providers regarding patient care transfers.
File Formats
- PDF — Standard format for most record deliveries.
- CCDA/CCD — Structured medical data format (XML-based) used for health information exchange.
- DICOM — Standard format for medical imaging files (X-rays, MRI, CT).
Medical Terminology Resources
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