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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 ...
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 ...
A nurses' station is an area of a health care facility (such as a hospital ward or nursing home ), which nurses and other health care staff work behind when not working directly with patients and where they can perform some of their duties. The station has a counter that can be approached by visitors and patients who wish to receive attention ...
Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
The Sigma Theta Tau International Honor Society of Nursing (ΣΘΤ) is the second-largest nursing organization in the world with approximately 135,000 active members. History [ edit ] In 1922 six Indiana University students at the Indiana University Training School for Nurses (the present-day IU School of Nursing ) founded Sigma Theta Tau at ...
Health system. A health system, health care system or healthcare system is an organization of people, institutions, and resources that delivers health care services to meet the health needs of target populations. There is a wide variety of health systems around the world, with as many histories and organizational structures as there are nations.
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