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Two types of patient records are electronic health records (EHRs), which are digital versions of patient charts, and paper-based medical records, which are physical documents containing patient information and medical history.
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Medical records use different formats. One of the most popular formats is the SOAP note. SOAP stands for:S = subjectiveO=objectiveA=assessmentP=PlanNote that the medical record rarely uses a "form" for physician notes, but uses a "format", often including a narrative section.Some institutions require SOAP notes from nurses, but other institutions use varying types of notes.
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Three types of medical information include:Family medical historyPersonal medical historyCurrent symptoms, medications, etc.
A medical coder types out codes then sends them to insurance companies
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Vetrenarian, Law, Medical,
medical and administrative
electronic and paper
Medical, Educational, and Assistive.