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The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD. It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way.
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 ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
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Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (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).
The Expert Field Medical Badge ( EFMB) is a United States Army special skills badge first created on June 18, 1965. This badge is the non-combat equivalent of the Combat Medical Badge (CMB) and is awarded to U.S. military personnel and North Atlantic Treaty Organization (NATO) military personnel who successfully complete a set of qualification ...
Purpose. 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 ...
Google Docs is an online word processor included as part of the free, web-based Google Docs Editors suite offered by Google, which also includes Google Sheets, Google Slides, Google Drawings, Google Forms, Google Sites and Google Keep.