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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.
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.
Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians.
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The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF, including adverse events.
Patient portals are healthcare-related online applications that allow patients to interact and communicate with their healthcare providers, such as physicians and hospitals. Typically, portal services are available on the Internet at all hours of the day and night.
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In healthcare, a change-of-shift report is a meeting between healthcare providers at the change of shift in which vital information about and responsibility for the patient is provided from the off-going provider to the on-coming provider (Groves, Manges, Scott-Cawiezell, 2016). [1]
Wristbands with barcodes that contain the information of the patient's medical record or visit number, and any other identifiers have been proven effective to provide proper patient care. In addition to wristbands, barcode scanners and printers are used to confirm patient identification.
The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction reviews, and checks on allergies and test or treatment conflicts. Physicians and nurses can review orders immediately for confirmation.