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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...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

    en.wikipedia.org/wiki/List_of_charting_software

    EditGrid – web-based spreadsheet with charting capabilities; Google Sheets – Online spreadsheet with built-in charting function for basic chart types; KChart – the charting tool of the Calligra Suite; LibreOffice Calc - Built-in charting function for basic chart types; Microsoft Excel – Built-in charting function for basic chart types

  4. 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 ...

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

  6. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.

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  8. Charting application - Wikipedia

    en.wikipedia.org/wiki/Charting_application

    A charting application is a computer program that is used to create a graphical representation (a chart) based on some non-graphical data that is entered by a user, most often through a spreadsheet application, but also through a dedicated specific scientific application (such as through a symbolic mathematics computing system, or a proprietary data collection application), or using an online ...

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