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Medical Record
A comprehensive document containing a patient’s health history, treatment plans, and medical interventions.
Written Care Plan
A detailed agreement documenting the management and treatment of a patient or resident, typically in a healthcare setting.
Focus Charting
A method of charting that uses key words or foci to describe what is happening to the client
Repetitive Charting
The act of documenting the same information multiple times in patient records, which can lead to inefficiency and increased risk of errors in healthcare settings.
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