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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 ...
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.
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 ...
Blood pressure is a measurement of the extent of the force of blood on your blood vessel walls as your heart pumps. It’s measured in millimeters of mercury (mm Hg). Systolic blood pressure is ...
Two commonly used tests are Snellen and random E. Snellen. The Snellen test uses a chart of letters or symbols. You’ve probably seen the chart in a school nurse’s office or eye doctor’s office.
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 ...
The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, but differences between the models are now being defined. The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record ...
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