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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 review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
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 ...
A pain scale is a tool that doctors use to help assess a person’s pain. A person usually self-reports their pain using a specially designed scale, sometimes with the help of a doctor, parent, or ...
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 ...
To help compensate for this problem, many doctors rely on pain scales to get a more concrete sense of a person's pain. You might have seen a pain scale in your doctor's office before. One common ...
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 ...