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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 ...
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 ...
History of the present illness. Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint ( HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain ).
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 ...
The bottom of the first sheet, the top and bottom of the second sheet, and the top of the third sheet are chemically treated so that the impression of the first sheet comes on the second and third sheets. Errors. It is possible for optical answer sheets to be printed incorrectly, such that all ovals will be read as filled.
Medication package insert. A package insert is a document included in the package of a medication that provides information about that drug and its use. For prescription medications, the insert is technical, providing information for medical professionals about how to prescribe the drug. Package inserts for prescription drugs often include a ...
Grand rounds. Grand rounds are a methodology of medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, pharmacists, residents, and medical students. It was first conceived by clinicians as a way for junior colleagues to round on patients. [1]
Vaccine Information Statement. A Vaccine Information Statement (VIS) is a document designed by the Centers for Disease Control and Prevention (CDC) to provide information to a patient receiving a vaccine in the United States. The National Childhood Vaccine Injury Act requires that medical professionals provide a VIS to patients before receiving ...
The Tuskegee Study of Untreated Syphilis in the Negro Male [1] [2] [3] (informally referred to as the Tuskegee Experiment or Tuskegee Syphilis Study) was a study conducted between 1932 and 1972 by the United States Public Health Service (PHS) and the Centers for Disease Control and Prevention (CDC) on a group of nearly 400 African American men ...
The Ballard Maturational Assessment, Ballard Score, or Ballard Scale, is a commonly used technique of gestational age assessment. It was devised by Dr Jeanne L. Ballard, Professor Emeritus of Pediatrics, Obstetrics and Gynecology at the University of Cincinnati College of Medicine. The assessment assigns a score to various criteria, the sum of ...