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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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.

  3. 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 ...

  4. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.

  5. 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 ...

  6. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history. The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the ...

  7. HCA makes bigger profits, scores lower with patients - AOL

    www.aol.com/hca-makes-bigger-profits-scores...

    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 ...

  8. 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 ...

  9. Patient-reported outcome - Wikipedia

    en.wikipedia.org/wiki/Patient-reported_outcome

    A patient-reported outcome ( PRO) is a health outcome directly reported by the patient who experienced it. It stands in contrast to an outcome reported by someone else, such as a physician -reported outcome, a nurse -reported outcome, and so on. PRO methods, such as questionnaires, are used in clinical trials or other clinical settings, to help ...

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