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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.
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 workflow ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
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 tumor grade reflects how likely it is to grow and spread. In general, this is what those grades mean: Grade 1: Low grade, or well-differentiated: The cells look a little different than regular ...
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 ...
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