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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.
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 ...
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 ...
Consults the medicine’s label and the patient’s chart to confirm when it should be administered. Right Route In this scenario, the word “route” is defined as how and where a patient takes ...
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 ...
A full score of 60 points indicates complete independence. Barthel Index. This 100-point scale assesses 10 activities in people who have had a stroke. Each activity is scored between 0 and 10 or 0 ...
diabetes. HIV. anemia. cancer. coronary heart disease. Even if a person does not have heart disease, a blood test can show whether they may be at risk of developing the condition. Other blood ...
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 ...
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