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Informed consent - Wikipedia Patient understanding An often-overlooked aspect of valid informed consent is the patient's understanding of terminology and outcomes The physician must explain the procedure, benefits, risks, and alternatives in words the patient can understand, as well as ensure that the patient does understand the information being relayed [12]
Medical record - Wikipedia 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 care across time within one particular health care provider's jurisdiction [1] A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and
Pain Treatment Agreement for Chronic Pain Treatment - WebMD The use of a pain management agreement allows for the documentation of understanding between a doctor and patient Such documentation, when used as a means of facilitating care, can improve
SOAP note - Wikipedia 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 workflow starting with appointment scheduling, patient check-in