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O*NET detailed work activityRecord patient medical histories
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Part of Maintain health or medical records, under the O*NET work activity group Documenting/Recording Information. Individual tasks below can carry a different label when their own wording calls for it (7 AI-ready, 54 AI-assist, 15 stays human).
Tasks built on this activity
- Collect, record, and maintain patient information, such as medical history, reports, or examination results.
- Obtain, compile, and record patient medical data, including health history, progress notes, and results of physical examination.
- Take and document patients' medical histories.
- Maintain patient records at all stages, including initial and subsequent evaluation and treatment activities.
- Take and document patients' medical histories.
- Document patients' histories, including identifying data, chief complaints, illnesses, previous medical or family histories, or psychosocial characteristics.
- Document patients' health histories, symptoms, physical conditions, or other diagnostic information.
- Measure and record lens power, using lensometers.
- Record type and amount of anesthesia and patient condition throughout procedure.
- Maintain patients' records.
- Record and review patient medical histories.
- Maintain complete and detailed records of patients' health care plans and prognoses.
- Collect, record, and maintain patient information, such as medical histories, reports, or examination results.
- Document patients' medical and psychological histories, physical assessment results, diagnoses, treatment plans, prescriptions, or outcomes.
- Collect, record, and maintain patient information, such as medical history, reports, or examination results.
- Document findings of physical examinations.
- Record athletes' medical histories, and perform physical examinations.
- Record patients' health histories.
- Document or evaluate patients' medical histories.
- Measure and record lens power, using lensometers.
- Document patients' medical histories.
- Complete and maintain necessary records.
- Maintain detailed and complete records of health care plans and prognoses.
- Record, process, and maintain patient data or treatment records and prepare reports.
- Maintain accurate case histories of patients.
- Record and process results of procedures.
- Interview patients or review medical records to obtain comprehensive patient or family medical histories, and document findings.
- Document data related to patients' care, including assessment results, interventions, medications, patient responses, or treatment changes.
- Document examination results, treatment plans, and patients' outcomes.
- Record athletes' medical care information, and maintain medical records.
- Chart conditions of decay and disease for diagnosis and treatment by dentist.
- Prepare diagnostic and treatment records.
- Maintain records of customer prescriptions, work orders, and payments.
- Obtain and record patient identification, medical history, or test results.
- Record patients' medical information and vital signs.
- Collect, record, and maintain patient information, such as medical history, reports, or examination results.
- Obtain and record patients' medical histories.
- Document patients' medical histories and assessment findings.
- Document the performance, interpretation, or outcomes of all procedures performed.
- Prepare, maintain, or review records that include patients' histories, neurological examination findings, treatment plans, or outcomes.
- Establish or maintain patient profiles, including lists of medications taken by individual patients.
- Gather and maintain patient information and records, including social or medical history obtained from patients, relatives, or other professionals.
- Document patients' treatment plans, interventions, outcomes, or plan revisions.
- Maintain documentation of all patients' contacts, reviewing and updating records as necessary.
- Maintain records that include patient information, sonographs and interpretations, files of correspondence, publications and regulations, or quality assurance records, such as pathology, biopsy, or post-operative reports.
- Record food and fluid intake and output.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Maintain files and records of surgical procedures.
- Obtain and record patient information, including patient identification, medical history, and examination results.
- Prepare case histories.
- Prepare case histories.
Tasks where it is part of the work
- Obtain and record accurate patient history, including prior test results or information from physical examinations.
- Document patient information, such as notes on their progress.
- Collect and record patient information, such as medical history or examination results, in electronic or handwritten medical records.
- Calculate, measure, and record radiation dosage or radiopharmaceuticals received, used, and disposed, using computer and following physician's prescription.
- Record prognosis, treatment, response, and progress in patient's chart or enter information into computer.
- Document or review patients' histories.
- Test and measure patient's strength, motor development and function, sensory perception, functional capacity, or respiratory or circulatory efficiency and record data.
- Collect and document patients' pre-anesthetic health histories.
- Observe and document client reactions, progress, or other outcomes related to art therapy.
- Perform and document an initial exam, evaluating data to identify problems and determine a diagnosis prior to intervention.
- Perform pre-anesthetic screenings, including physical evaluations and patient interviews, and document results.
- Observe patients, charting and reporting changes in patients' conditions, such as adverse reactions to medication or treatment, and taking any necessary action.
- Identify and document goals, anticipated progress, and plans for reevaluation.
- Measure and record patients' vital signs, such as height, weight, temperature, blood pressure, pulse, or respiration.
- Observe and document client reactions, progress, or other outcomes related to music therapy.
- Monitor, record, and report symptoms or changes in patients' conditions.
- Document evaluations, treatment plans, case summaries, or progress or other reports related to individual clients or client groups.
- Observe, record, and report to physician the patient's condition or injury, the treatment provided, and reactions to drugs or treatment.
- Observe, analyze, and record patients' participation, reactions, and progress during treatment sessions, modifying treatment programs as needed.
- Administer prescribed medications or start intravenous fluids, noting times and amounts on patients' charts.
- Visit and observe patients on hospital rounds or house calls, updating charts, ordering therapy, and reporting back to physician.
- Monitor and document patients' progress during post-anesthesia period.
- Take and record measures of patients' physical condition, using devices such as thermometers or blood pressure gauges.
- Document or review comprehensive patients' histories with an emphasis on occupation or environmental risks.
- Observe, record, and report to physician the patient's condition or injury, the treatment provided, and reactions to drugs or treatment.