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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 ...
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 ...
The ideal stool is generally type 3 or 4, easy to pass without being too watery. If yours is type 1 or 2, you're probably constipated. Types 5, 6, and 7 tend toward diarrhea. Ken Heaton, MD, from ...
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 ...
Whole-grain bread, English muffin, or bagel. Whole-grain waffles or pancakes with fruit. Lean protein (low in saturated fat): A higher omega-3 egg blended with 2 egg whites for an egg dish. Add ...
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 ...
In this case, positive doesn’t necessarily mean “good” and negative doesn’t necessarily mean “bad.”. Instead: Positive: The lab found whatever your doctor was testing for. So if you ...
Examples of somatic pain include: bone fractures. strained muscles. connective tissue diseases, such as osteoporosis. cancer that affects the skin or bones. skin cuts, scrapes, and burns. joint ...
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