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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 ...
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 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 ...
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 ...
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 ...
The audiogram is a fairly simple graph: The Y-axis (vertical) measures the intensity, or loudness, of the sound. It’s measured in decibels (Db) and ranges from -10 to 110 on the audiogram. Low ...
A dental chart, also called a periodontal chart, is where your dental healthcare professional records the condition of your teeth and gums. ... With better home care, for example, gum pockets ...
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 ...