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It should not however, be used as a replacement for the gonioscopy examination but rather be used as a means of refuting or confirming the results of a gonioscopy examination. [3] The Van Herick's technique has become the most commonly used qualitative method of assessing the size of the anterior chamber angle (ACA).
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
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.
In ophthalmology, gonioscopy is a routine procedure that measures the angle between the iris and the cornea (the iridocorneal angle), using a goniolens (also known as a gonioscope) together with a slit lamp or operating microscope. [1] [2] Its use is important in diagnosing and monitoring various eye conditions associated with glaucoma.
Supporting documents can be added to the original document as an attachment for clarification or recording data. Attachments should be referenced at least once within the original document. Ideally, each page of the attachment is clearly identified (i.e. labeled as "Attachment X", "Page X of X", signed and dated by person who attached it, etc.)
Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...