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2. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

3. 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 ...

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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

5. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...

6. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]

7. Point of care - Wikipedia

   en.wikipedia.org/wiki/Point_of_care

   Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]

8. Medication package insert - Wikipedia

   en.wikipedia.org/wiki/Medication_package_insert

   PILLS (Patient Information Language Localisation System) is a one-year effort by the European Commission to produce a prototype tool which will support the creation of various kinds of medical documentation simultaneously in multiple languages, by storing the information in a database and allowing a variety of forms and languages of output.

9. List of abbreviations used in medical prescriptions - Wikipedia

   en.wikipedia.org/wiki/List_of_abbreviations_used...

   twice daily bib. bibe: drink bis bis: twice b.i.d., b.d. bis in die: twice daily AMA style avoids use of this abbreviation (spell out "twice a day") bis ind. bis indies: twice a day bis in 7 d. bis in septem diebus: twice a week BM bowel movement: commonly used in the United Kingdom when discussing blood sugar.