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Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
The APS summaries, however, are only as good as the underwriter's experience, which varies widely from person to person. Additionally, APS summaries, when processed without a “template structure” guiding the information gathered from the APS, often yield inconsistent or miss critical underwriting information.
[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
A form letter is a letter written from a template, rather than being specially composed for a specific recipient.The most general kind of form letter consists of one or more regions of boilerplate text interspersed with one or more substitution placeholders.
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Regulatory documents can be huge and are formulaic. They include clinical study protocols, clinical study reports, patient informed consent forms, investigator brochures and summary documents (e.g. in Common Technical Document [CTD] format) that summarize and discuss the data a company gathers in the course of developing a medical product.
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