Glossary
Look up the terms behind a clinical workup
Find the words doctors use in assessments, referrals, handovers and AI tools. Each entry gives the definition first, then how to put it into practice.
All terms
- Audit trailAn audit trail records who viewed, added, changed, shared or exported a record and when, so access can be reviewed and incidents investigated.
- Clinical reasoningClinical reasoning is how a clinician gathers information, weighs it and reaches a diagnosis and plan, including the checks against common errors.
- Data processing agreementA data processing agreement is the contract under which a vendor processes personal data for your organization. In US healthcare the equivalent is a BAA.
- De-identificationDe-identification removes or alters details that identify a patient, such as name, date of birth and record numbers. It lowers risk but rarely removes it.
- Differential diagnosisA differential diagnosis is a ranked list of the conditions that could explain a patient's problem, with the reasoning for each position.
- Discharge summaryA discharge summary tells the patient's primary care physician what happened in the hospital: diagnoses, treatment, medication changes and what needs follow-up.
- GroundingGrounding means an AI tool answers from a given set of sources rather than from general training data, and can point to the passage it used.
- HallucinationA hallucination is a statement an AI tool produces that sounds plausible but is not supported by its sources or by fact, such as an invented result.
- HandoverA handover transfers responsibility for a patient from one clinician or team to another, with the information they need to continue care.
- History of presenting complaintThe history of presenting complaint is the detailed story of the main problem: onset, character, timing, triggers, relieving factors and associated symptoms.
- Medication reconciliationMedication reconciliation compares every list of a patient's medicines to produce one accurate list of what they actually take, with doses.
- Pre-test probabilityPre-test probability is how likely a condition is before a test, based on age, sex, risk factors and symptoms. It decides how much a result should move you.
- Presenting complaintThe presenting complaint is the main problem that brought the patient in, recorded in a short phrase and ideally in the patient's own words.
- Problem listA problem list is a running list of a patient's active and past diagnoses and issues, kept current so any clinician sees the whole picture at a glance.
- Red flagsRed flags are history or examination features that raise the likelihood of a serious cause and call for prompt action or further assessment.
- Referral letterA referral letter asks another clinician a specific question about a patient and gives them the history and results they need to answer it.
- Review of systemsA review of systems is a structured set of questions about each body system, asked to find symptoms the patient did not mention.
- Safety-nettingSafety-netting is the advice you give a patient about which symptoms should bring them back, how urgently and to whom, recorded in the notes.
- SBARSBAR is a structure for clinical communication: Situation, Background, Assessment and Recommendation. It is widely used for handovers and escalation.
- SOAP noteA SOAP note structures a clinical entry as Subjective, Objective, Assessment and Plan, separating what the patient reports from what you found and concluded.
- Source documentA source document is the original record a fact comes from, such as a lab report, an ECG report or a letter. Checking it is how you verify a statement.
- Structured noteA structured note follows fixed headings, such as history, findings, assessment and plan, so omissions stand out and readers find information fast.
- Working diagnosisA working diagnosis is the explanation you act on until new information confirms or replaces it, usually the top of your differential.
- WorkupA workup is the process of assessing a patient's problem: gathering sources, taking the history, examining, investigating and writing the assessment.