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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 ...
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] 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 ...
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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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. Some patient portal applications exist as stand-alone web sites and sell their ...
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 ...