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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 ...
A written record of the history, treatment, care, and response of the client while under the care of a health care provider. A guide for reimbursement of care costs. Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process.
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 ...
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 ...
Braden Scale for Predicting Pressure Ulcer Risk. The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. [1] The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer. [2]
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 ...
Aug. 9—Three New Hampshire hospitals owned by the company trying to buy Catholic Medical Center have reaped industry-leading profits while receiving the lowest ratings from their patients ...
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