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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 ...
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 ...
Treatments. A nurse may teach you how to take medications or use inhalers to treat your COPD. You may also need the assistance of a home health nurse or — during acute episodes — inpatient ...
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).
0 points: absent. 1 point: irregular, weak crying. 2 points: good, strong cry. The Apgar scores are recorded at one and five minutes. This is because if a baby’s scores are low at one minute, a ...
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 ideal stool is generally type 3 or 4, easy to pass without being too watery. If yours is type 1 or 2, you're probably constipated. Types 5, 6, and 7 tend toward diarrhea. Ken Heaton, MD, from ...
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 ...