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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 ...
Second, medical roots generally go together according to language, i.e., Greek prefixes occur with Greek suffixes and Latin prefixes with Latin suffixes. Although international scientific vocabulary is not stringent about segregating combining forms of different languages, it is advisable when coining new words not to mix different lingual roots.
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 ...
List of medical abbreviations: 0–9. Dx - Diagnosis, Sx - Symptoms, Fx - Fracture, Tx - Treatment, Hx - History S/b-seen by.
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 ...
The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, but differences between the models are now being defined. The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record ...
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