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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 ...
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 ...
Dental charting is a process in which your dental healthcare professional lists and describes the health of your teeth and gums. Periodontal charting, which is a part of your dental chart, refers ...
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 ...
body temperature. heart rate (the rate of your heartbeat) respiratory rate (rate of breathing) blood pressure. oxygen saturation (the amount of oxygen circulating in your blood) Vital signs are ...
The chart below outlines the recommended blood sugar range for people who are pregnant and have type 1 diabetes. Time. Recommended blood sugar range. Fasting (before eating) Lower than 95 mg/dL. 1 ...
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 ...
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