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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...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

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [ 1][ 2] Documenting patient encounters in the medical record is an integral part of practice ...

  5. List of abbreviations used in medical prescriptions - Wikipedia

    en.wikipedia.org/wiki/List_of_abbreviations_used...

    used exclusively in veterinary medicine sig. signa, signetur: write (write on the label) s̄ sine: without (usually written with a bar on top of the s) sing. singulorum: of each SL, s.l. sub lingua: sublingually, under the tongue SOB shortness of breath sol. solutio: solution s.o.s., si op. sit si opus sit: if there is a need s.s., SS

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  7. Electronic health records in the United States - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_records...

    Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records.The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use ...

  8. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...

  9. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [ 6][ 7] In contrast, a ...

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