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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 ...
Laura Brooks. . . ( m. 1952; died 1997) . Children. 5. Lawrence Leonard Weed (December 26, 1923 – June 3, 2017) [1] was an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records. [2]
Medical nutrition therapy is a specialized, dietician-developed regimen used to treat certain diseases, such as diabetes. This article tells you everything you need to know about medical nutrition ...
The leading source for trustworthy and timely health and medical news and information. Providing credible health information, supportive community, and educational services by blending award ...
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.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
AVPU. The AVPU scale (an acronym from "alert, verbal, pain, unresponsive") is a system by which a health care professional can measure and record a patient's level of consciousness. [1] It is mostly used in emergency medicine protocols, and within first aid. It is a simplification of the Glasgow Coma Scale, which assesses a patient response in ...
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