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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...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. File:COVID-19 Vaccination Record Card CDC (8-17-2020).pdf

    en.wikipedia.org/wiki/File:COVID-19_Vaccination...

    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

  4. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  6. Early warning system (medical) - Wikipedia

    en.wikipedia.org/wiki/Early_warning_system_(medical)

    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]

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  8. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    If a malpractice claim goes to court, through the process of discovery, the prosecution can request a detailed record of all entries made in a patient's electronic record. Waiting to chart patient notes until the end of the day and making addendums to records well after the patient visit can be problematic, in that this practice could result in ...

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