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A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
mean arterial pressure: MAR: Medication Administration Record: MARSA: methicillin- and aminoglycoside-resistant Staphylococcus aureus: MAS: Morgagni–Adams–Stokes syndrome meconium aspiration syndrome MAST: Michigan alcohol screening test: MAT: multifocal atrial tachycardia microscopic agglutination test medication-assisted treatment. MBSS ...
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. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
take (often effectively a noun meaning "prescription"—medical prescription or prescription drug) rep. repetatur: let it be repeated s. signa: write (write on the label) s.a. secundum artem: according to the art (accepted practice or best practice) SC subcutaneous "SC" can be mistaken for "SL," meaning sublingual. See also SQ: sem. semen seed ...
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.
Minimal residual disease (MRD), also known as Molecular residual disease, is the name given to small numbers of cancer cells that remain in a person either during or after treatment when the patient is in remission (no symptoms or signs of disease).
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.