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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. 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 ...

4. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...

5. SF-12 - Wikipedia

   en.wikipedia.org/wiki/SF-12

   SF-12. The Short Form (12) Health Survey is a 12-item, patient-reported survey of patient health. It is a reduced size version of the SF-36, and is widely used since it produces similar results for physical and mental health scores with far less respondent burden for producing scores of overall mental and physical well-being. [1] [2] [3]

6. Nursing care plan - Wikipedia

   en.wikipedia.org/wiki/Nursing_care_plan

   A nursing care plan provides direction on the type of nursing care the individual/family/community may need. [1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. [2] Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the ...

7. SAMPLE history - Wikipedia

   en.wikipedia.org/wiki/SAMPLE_History

   SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. The SAMPLE history is sometimes used in conjunction with vital signs ...