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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.
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP ...
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 ...
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 ...
A pathology report is a medical document that gives information about a diagnosis, such as cancer. To test for the disease, a sample of your suspicious tissue is sent to a lab. A doctor called a ...
diabetes. HIV. anemia. cancer. coronary heart disease. Even if a person does not have heart disease, a blood test can show whether they may be at risk of developing the condition. Other blood ...
ketones. presence in urine is abnormal, may indicate diabetes. albumin. presence is abnormal, may indicate kidney disease. protein. presence is abnormal, may indicate kidney disease. bilirubin ...
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 ...
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