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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 ...
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 ...
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 ...
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 ...
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 ...
When a healthcare provider recommends a specific procedure, you have the right to accept or refuse it. If you decide to move forward, you’ll need to give informed consent first. Informed consent ...
Step 2: Check your doctor's website. If you visit a medical practice, your doctor may have details on how to request your medical record on their website. Step 3: Call or e-mail your doctor ...
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 ...
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