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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.
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.
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.
In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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