nursing notes(A nursing note is a medical note into a medical or health record made by a nurse that can provide an accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care. practicefusion.comnightwolf2011)
Medical Records(Документы, содержащие медицинскую информацию о пациенте. В условиях клиники медицинская информация о пациенте содержится в амбулаторной карте, истории болезни и т.д. Andy)