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  2. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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 ...

  4. List of PDF software - Wikipedia

    en.wikipedia.org/wiki/List_of_PDF_software

    Proprietary software for viewing and editing PDF documents. pdftk: GNU GPL/Proprietary: command-line tools to manipulate, edit and convert documents; supports filling of PDF forms with FDF/XFDF data. PDF-XChange Viewer: Freeware: Freeware PDF reader, tagger, editor (simple editions) and converter (free for non-commercial uses).

  5. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

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  7. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...

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  9. Point of care - Wikipedia

    en.wikipedia.org/wiki/Point_of_care

    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]

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