Document
Document (Medicine)
A Document (pronounced: /ˈdɒkjʊmənt/) in the field of medicine refers to a written, drawn, presented, or memorialized representation of thought, often the manifestation of non-fictional, as well as, fictional content.
Etymology
The term "Document" originates from the Latin word documentum, which means a "teaching" or "lesson". The word was adopted into English in the 15th century from the Old French document.
Medical Usage
In medicine, a document often refers to a formal written or printed record that provides information, evidence, or serves as an official record. This can include medical records, prescriptions, lab reports, and patient consent forms.
Medical Records
A medical record is a systematic documentation of a patient's medical history and care. It is made up by the healthcare professional and includes a variety of information, such as patient's medical history, examination findings, and treatment plans.
Prescriptions
A prescription is a health-care program implemented by a physician or other qualified health care practitioner in the form of instructions that govern the plan of care for an individual patient.
Lab Reports
Lab reports are written documents that detail the procedures and outcomes of a laboratory process or experiment.
Patient Consent Forms
A patient consent form is a document that is used to capture the informed consent of a patient for a medical procedure.
Related Terms
- Electronic Health Record (EHR): An electronic version of a patient's medical history that is maintained by the healthcare provider over time.
- Medical Transcription: The process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners.
- Medical Coding: The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
External links
- Medical encyclopedia article on Document
- Wikipedia's article - Document
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