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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Epic Systems Corporation (commonly known as Epic) is an American privately held healthcare software company based in Verona, Wisconsin. According to the company, hospitals that use its software held medical records of 78% of patients in the United States and over 3% of patients worldwide in 2022.
The JKL Healthcare System was one of the first successful implementers of EMR using the Epic System, and they became a model site for other healthcare systems. JKL Healthcare received the Davies Award in September 2004, which is the most prestigious award in the IT industry for its implementation of the most comprehensive EMR system in the US.
VISTA's Architecture is an "Onion" with concentric layers of functions. At its core is a single shared database that all applications use. The Veterans Health Information Systems and Technology Architecture (VISTA) is the system of record for the clinical, administrative and financial operations of the Veterans Health Administration [1] VISTA consists of over 180 clinical, financial, and ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. 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.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Another disadvantage to using SBAR when bedside charting is the issue of disclosing sensitive topics or new information that has not been shared with the patient or family before or after the bedside charting takes place. An alternative to this can be for nurses to makes plans to share new or sensitive information before or after bedside report ...
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 required anywhere from several times an hour to several times a day.