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A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
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 ...
Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
Some general recommendations for healthy eating with diabetes include: learning what serving and portion sizes look like. monitoring sugar and learning what items contain added sugar. drinking ...
Dental charting is a process in which your dental healthcare professional lists and describes the health of your teeth and gums. Periodontal charting, which is a part of your dental chart, refers ...
A pathology report is a medical document that gives information about a diagnosis, such as cancer. To test for the disease, a sample of your suspicious tissue is sent to a lab. A doctor called a ...
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