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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 ...
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital signs and OPQRST. The questions are most commonly used in the field of emergency medicine by first responders during the secondary assessment.
Do you know all of the details of your medical history? Learn what a personal and family medical history is, why you need to know it and how to gather the information.
Trying to make sense of your lab test results? Learn more about what they mean -- and what you need to do next.
A dental chart, also called a periodontal chart, is where your dental healthcare professional records the condition of your teeth and gums.
Learn how to read a blood pressure chart. Also get the facts on hypotension, hypertension, how to measure your blood pressure, and more.
The Bristol Stool Scale is a way to talk about shapes and types of poop, what doctors call stools. It's also known as the Meyers Scale. The chart is designed to help doctors measure the time it ...
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