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The electronic medical record includes templates for certain aspects of care such as vital signs, medications, and lab tests.
Hospital admissions database: the patient's medical record includes written consent given on admission.
The archived complete medical record includes the admission note, first progress note, subsequent progress notes, discharge summary, prescription and lab results, as well as nursing notes.
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The pharmacist will also review participants' general practice medical record (including progress notes, medication lists and pathology results) and dispensing histories if needed.
Additional information was collected on subjects' medical record, including the use of medication.
Using a secure identification card, a patient can make an appointment with a doctor or review her own medical record, including results from tests or scans.
Records were reviewed using the electronic medical record including ED notes, discharge summaries, information on prior and subsequent visits, and all laboratory and radiologic tests.
The nurse-trained abstractor reviewed the medical record, including notes of medical and nursing staff.
All components of each subject's medical record, including all volumes of paper records and all electronic records, were reviewed.
Hospital coders use all available information in the medical record, including the MDC form, to code diagnoses and procedures.
Established risk factors for heart disease that are documented in the electronic medical record include hypertension, hyperlipidemia, and obesity.
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