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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. 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 ...

4. 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 ...

5. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   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 ...

6. Nursing assessment - Wikipedia

   en.wikipedia.org/wiki/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. Incident report - Wikipedia

   en.wikipedia.org/wiki/Incident_report

   Incident report. In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or accident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient. The purpose of the incident report is to document the exact details of ...

8. Operative report - Wikipedia

   en.wikipedia.org/wiki/Operative_report

   Operative report. An Operative report is a report written in a patient's medical record to document the details of a surgery. [1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after ...

9. Nursing research - Wikipedia

   en.wikipedia.org/wiki/Nursing_research

   Nursing research is research that provides evidence used to support nursing practices. Nursing, as an evidence-based area of practice, has been developing since the time of Florence Nightingale to the present day, where many nurses now work as researchers based in universities as well as in the health care setting. [citation needed] Nurse ...