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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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.
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care.
Medical-surgical nursing is a nursing specialty area concerned with the care of adult patients in a broad range of settings. Traditionally, medical-surgical nursing was an entry-level position that most nurses viewed as a stepping stone to specialty areas.
The Journal of Cutaneous Medicine and Surgery (abbreviated JCMS) is a bimonthly peer-reviewed medical journal covering dermatology.It was established in 1996 and is published by SAGE Publications in collaboration with the Canadian Dermatology Association, of which it is the official journal. [1]
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