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Patient check-in is the process where patients begin their registration with the healthcare facility topically using a clipboard, electronic tablet, touch screen, kiosk, or some other method, sometimes self-service. Patient check-ins start as far back as the Roman times when patients would wait for special services in purpose-built hospitals.
A Medication Administration Record (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 checklist places its nineteen items into three "phases" of a surgical procedure: sign-in (before induction of anesthesia, while the patient is still conscious); time-out (with the surgeon present, before skin incision); and sign-out, based on the Joint Commission's Universal Protocol.
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There are four primary vital signs: body temperature, blood pressure, pulse ( heart rate ), and breathing rate ( respiratory rate ), often notated as BT, BP, HR, and RR. However, depending on the clinical setting, the vital signs may include other measurements called the "fifth vital sign" or "sixth vital sign."
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
