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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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 ...
The post-mortem interval (PMI) is the time that has elapsed since an individual's death. [1] When the time of death is not known, the interval may be estimated, and so an approximate time of death established. Postmortem interval estimations can range from hours, to days or even years depending on the type of evidence present. [2]
These changes can generally be divided between early post-mortem changes and late post-mortem changes (also known as decomposition). [12] These changes occur along a continuum and can be helpful in determining the post-mortem interval, which is the time between death and examination. The stages that follow shortly after death are:
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
The last offices, or laying out, is the procedures performed, usually by a nurse, to the body of a dead person shortly after death has been confirmed. [1] They can vary between hospitals and between cultures .
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]
Nursing care plans provide continuity of care, safety, quality care and compliance. A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid . The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing ...
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