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  2. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note , where the note is organized into S ubjective, O bjective, A ssessment, and P lan sections.

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice ...

  4. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.

  5. 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 ...

  6. 50 Reassuring Facts Not Everyone Might Be Aware Of ... - AOL

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    Slow progress is still progress. This fact helped me get through high school and currently college. No matter how behind you are, you are closer to being caught up with each assignment you complete.

  7. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    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. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP ...

  8. Evaluation - Wikipedia

    en.wikipedia.org/wiki/Evaluation

    Evaluation. In common usage, evaluation is a systematic determination and assessment of a subject's merit, worth and significance, using criteria governed by a set of standards. It can assist an organization, program, design, project or any other intervention or initiative to assess any aim, realizable concept/proposal, or any alternative, to ...

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