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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. [2]
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 ...
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 created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6][7] In contrast, a ...
A pathology report is a medical document that gives information about a diagnosis, such as cancer. To test for the disease, a sample of your suspicious tissue is sent to a lab. A doctor called a ...
Blood pressure is measured in millimeters of mercury (mm Hg) and consists of two numbers, systolic and diastolic. A doctor uses these figures to categorize high blood pressure into stages. Blood ...
A doctor may order a blood sugar test to see if you have diabetes or prediabetes. The test will measure the amount of glucose in your blood. Your body takes carbohydrates found in foods like ...
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 ...
Examples of healthy protein foods for your diabetes meal plan include: Lean meats like skinless chicken and turkey breast. Seafood such as cod, tilapia, and tuna. Eggs. Low-fat dairy foods like ...
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