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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 ...
Continuity of Care Document. The Continuity of Care Document (CCD) specification is an XML -based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. [1]
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 recordis an integral part of practice workflow starting ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
Portal of Medical Data Models. The portal for medical data models is a German [1] and European [2] medical research infrastructure. It is an open-access metadata-repository initiated for scientific purposes that can generate, analyse, release and reuse medical forms.
Studierfenster (StudierFenster) is a free, non-commercial Open Science client/server-based Medical Imaging Processing (MIP) online framework. [ 52 ] Medical open network for AI is a framework for Deep learning in healthcare imaging that is open-source available under the Apache Licence and supported by the community.
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 ...
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.
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