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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.
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.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.
A medical sign is an objective observable indication of a disease, injury, or medical condition that may be detected during a physical examination. These signs may be visible, such as a rash or bruise , or otherwise detectable such as by using a stethoscope or taking blood pressure .
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SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR.
There are four primary vital signs which are standard in most medical settings: Body temperature; Heart rate or Pulse; Respiratory rate; Blood pressure; The equipment needed is a thermometer, a sphygmomanometer, and a watch. Although a pulse can be taken by hand, a stethoscope may be required for a clinician to take a patient's apical pulse.
Microsoft Office Excel, Google Sheets and Apple Numbers all include excellent built-in spreadsheet templates. If the provided templates aren’t enough, you can find more options online.
Eponymous medical signs are those that are named after a person or persons, usually the physicians who first described them, but occasionally named after a famous patient. This list includes other eponymous entities of diagnostic significance; i.e. tests, reflexes, etc.
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. The SAMPLE history is sometimes used in conjunction with vital signs and OPQRST. The questions are most commonly used in the field of emergency medicine by first responders during the secondary assessment.
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