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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 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 ...
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 ...
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. The SAMPLE history is sometimes used in conjunction with vital signs ...
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."
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Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes ( SOAP ...
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