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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.
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]
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
As stated in the 2006 IOM report, the limitations of HEDIS process measures include "sample size constraints for condition-specific measures," "may be confounded by patient compliance and other factors," and "variable extent to which process measures link to important patient outcomes" [14] (p. 179).
The use of medical equipment is routinely employed to conduct a nursing assessment. These include, the otoscope, thermometer, stethoscope, penlight, sphygmomanometer, bladder scanner, speculum, and eye charts. Besides the interviewing process, the nursing assessment utilizes certain techniques to collect information such as observation ...
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. [7] [8] EMRs are essentially digital versions of the paper charts used in a clinician’s office, typically functioning as an internal system within a practice.
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The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...