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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 ...
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 ...
Your medical history includes both your personal health history and your family health history. Your personal health history has details about any health problems you’ve ever had. A family ...
Type 4–6 stool refers to the Bristol Stool Scale, a tool for classifying stool types. Type 4 is smooth and soft, like a sausage or snake. Type 6 is fluffy with ragged edges, indicating mild ...
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 ...
Periodontal charting, which is a part of your dental chart, refers to the six measurements (in millimeters) that are taken around each tooth. The charting is usually done during dental checkups ...
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