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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 ...
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...
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 ...
A specific type of change-of-shift report is Nursing Bedside Shift Report in which the off going nurse provides change-of-shift report to the on coming nurse at the patient's bedside. [1] [5] [6] Since 2013, giving report at the patient bedside has been recommend by the Agency for Healthcare Research and Quality (AHRQ) to improve patient safety ...
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 ...
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [ 10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical ...
Over 200 nursing specialties and subspecialties are available. Studies from the Institute of Medicine have demonstrated that specialty-certified nurses have higher rates of patient satisfaction and lower rates of work-related errors in patient care. Registered nurses (RNs) are not required to be certified in a certain specialty by law. For ...