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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 ...
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 ...
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.
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 ...
Positive: The lab found whatever your doctor was testing for. So if you had a test for strep throat, testing positive means you do have strep throat. Negative: The lab didn’t find whatever you ...
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 ...
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 ...
ketones. presence in urine is abnormal, may indicate diabetes. albumin. presence is abnormal, may indicate kidney disease. protein. presence is abnormal, may indicate kidney disease. bilirubin ...