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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 ...
An early warning system (EWS), sometimes called a between-the-flags or track-and-trigger chart, is a clinical tool used in healthcare to anticipate patient deterioration by measuring the cumulative variation in observations, most often being patient vital signs and level of consciousness. [1]
This record is often called the patient's "chart" in a hospital setting. Medical transcription encompasses the medical transcriptionist, performing document typing and formatting functions according to an established criterion or format, transcribing the spoken word of the patient's care information into a written, easily readable form.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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Google Docs is an online word processor and part of the free, web-based Google Docs Editors suite offered by Google. Google Docs is accessible via a web browser as a web-based application and is also available as a mobile app on Android and iOS and as a desktop application on Google's ChromeOS .
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