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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.
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.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
every day / daily quaque die q.h.s., qhs every night at bedtime quaque hora somni q.d.s, qds, QDS 4 times a day quater die sumendum q.i.d, qid 4 times a day quater in die q.h., qh every hour, hourly quaque hora q.o.d., qod every other day / alternate days quaque altera die q.p.m., qPM, qpm every afternoon or evening: quaque post meridiem q.s., qs
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My#System#for#Making#Sure#I#Do#What#Matters# #! With!all!the!devices!we!use!on!a!daily!basis,!I!still!like!to!make!my!to7do!lists!with!pen!to! paper!!!I!find!it!is ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]