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COVID-19 Vaccination Record Card: Image title: COVID-19 Vaccination Record Card: Author: CDC/NCIRD: Software used: Adobe InDesign CC 13.0 (Windows) Conversion program: Adobe PDF Library 15.0: Encrypted: no: Page size: 348 x 294 pts: Version of PDF format: 1.4
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...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 medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
[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 ...