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The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
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 personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
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 ...
The National Highway Safety Administration (NHTSA) uses BAC standard drink measurements of: 12-ounce beer. 5-ounce table wine. 1.5-ounce 80-proof liquor. Intoxication levels depend on how quickly ...
Let’s say that you check your blood sugar before a meal and it’s 170. You’ll need 1 unit of fast-acting insulin to adjust to your target of 120. If you plan to eat a meal that has 60 grams ...
Consults the medicine’s label and the patient’s chart to confirm when it should be administered. Right Route In this scenario, the word “route” is defined as how and where a patient takes ...
A patient portal is a secure website set up by a health care system, hospital, or clinic. The tools (or features) vary, depending on the portal. Patient portals can help you access medical records ...
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