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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 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).
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 ...
Right Dose. Right Time. Right Route. Right Documentation. Right Response. Tips for Medication Administration. 4 min read. One of the most serious responsibilities that health care providers have ...
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 ...
body temperature. heart rate (the rate of your heartbeat) respiratory rate (rate of breathing) blood pressure. oxygen saturation (the amount of oxygen circulating in your blood) Vital signs are ...
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 ...