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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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [14] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number.
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
COVID-19 Vaccination Record Card: Image title: COVID-19 Vaccination Record Card: Author: CDC/NCIRD: Software used: Adobe InDesign CC 13.0 (Windows) Conversion program: Adobe PDF Library 15.0: Encrypted: no: Page size: 348 x 294 pts: Version of PDF format: 1.4
Rescission is the noun form of the verb "to rescind." It may refer to: Rescission (contract law) Rescission bill, a procedure to rescind previously appropriated funding in the United States; A synonym for repeal in parliamentary procedure; Several bills which have used the term in their names:
A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR [3]), no code [4] [5] or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. [5]
The MOLST Program is a New York State initiative that facilitates end-of-life medical decision-making. One goal of the MOLST Program is to ensure that decisions to withhold or withdraw life-sustaining treatment are made in accordance with the patient's wishes, or, if the patient's wishes are not reasonably known and cannot with reasonable diligence be ascertained, in accordance with the ...
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