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SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
ketones. presence in urine is abnormal, may indicate diabetes. albumin. presence is abnormal, may indicate kidney disease. protein. presence is abnormal, may indicate kidney disease. bilirubin ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
A mock-up of a TPS report cover sheet, created for the movie Office Space. A TPS report ("test procedure specification") is a document used by a quality assurance group or individual, particularly in software engineering, that describes the testing procedures and the testing process.
It’s a test to check for germs or bacteria in your pee that can cause a urinary tract infection ( UTI ). Your urinary tract includes the kidneys, bladder, and the tubes that carry your pee ...
A tumor grade reflects how likely it is to grow and spread. In general, this is what those grades mean: Grade 1: Low grade, or well-differentiated: The cells look a little different than regular ...
Another example of an After Action Report is the global status reported on road safety. Studies are conducted in order to determine how severe road safety concerns are in a particular area. After this, a report is created over the conditional event that is road safety, and a reflection is written with insight into how road safety can be improved.
A presentence investigation report ( PSIR) is a legal document that presents the findings of an investigation into the "legal and social background" of a person convicted of a crime before sentencing to determine if there are extenuating circumstances which should influence the severity or leniency of a criminal sentence.