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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 ...
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 medical procedure is a course of action intended to achieve a result in the delivery of healthcare . A medical procedure with the intention of determining, measuring, or diagnosing a patient condition or parameter is also called a medical test. Other common kinds of procedures are therapeutic (i.e., intended to treat, cure, or restore ...
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.
Medical law. Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. The scope of practice is limited to that which the law allows for specific education and experience, and specific demonstrated competency.
Whether a policy or guideline is an accurate description of best practice is determined through consensus. On discussion pages and in edit summaries, shortcuts are often used to refer to policies and guidelines; for example, (no original research), (neutral point of view) and (biographies of living persons). Similar shortcuts are also used for ...
Many surgical procedure names can be broken into parts to indicate the meaning. For example, in gastrectomy, "ectomy" is a suffix meaning the removal of a part of the body. "Gastro-" means stomach. Thus, gastrectomy refers to the surgical removal of the stomach (or sections thereof).