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Patient check-in. 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 by other method, sometimes self-service. Patient check-in start as far back as the Roman times when patients would wait for special services in purpose ...
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 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 draw sheet is commonly used to assist in lifting or repositioning the patient. Sheets positioned under the patient are securely tucked in to prevent the formation of wrinkles, which can contribute to skin breakdown. A top sheet and a blanket are then placed over the bed, with the corners neatly mitered. [31]
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Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...