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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Mass General Brigham (MGB) (formerly Partners HealthCare) is a not-for-profit, [5] integrated health care system [6] that engages in medical research, [7] teaching, [8] and patient care. It is the largest hospital-based research enterprise in the United States, with annual funding of more than $2 billion. [ 9 ]
Massachusetts General Hospital (Mass General or MGH) is a teaching hospital located in the West End neighborhood of Boston, Massachusetts. [4] It is the original and largest clinical education and research facility of Harvard Medical School/Harvard University, and houses the world's largest hospital-based research program with an annual research budget of more than $1.2 billion in 2021. [5]
Physicians are generally required to generate at least one progress note for each patient encounter. 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 ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
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Record and chart changes in vital signs. Record smoking status for patients 13 years old or older. Implement one clinical decision support rule. Report ambulatory quality measures to CMS or the States. Provide patients with an electronic copy of their health information upon request. Provide clinical summaries to patients for each office visit.
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