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2. Medication Administration Record - Wikipedia

   en.wikipedia.org/wiki/Medication_Administration...

   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 ...

3. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   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 ...

4. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   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 ...

5. Change-of-shift report - Wikipedia

   en.wikipedia.org/wiki/Change-of-shift_report

   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 ...

6. Nursing assessment - Wikipedia

   en.wikipedia.org/wiki/Nursing_assessment

   Nursing assessment. 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.

7. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   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 ...

8. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   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 ...

9. Patient-Reported Outcomes Measurement Information System

   en.wikipedia.org/wiki/Patient-Reported_Outcomes...

   The Patient-Reported Outcomes Measurement Information System [1] ( PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...