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The health information systems literature has seen the EHR as a container holding information about the patient, and a tool for aggregating clinical data for secondary uses (billing, audit, etc.). However, other research traditions see the EHR as a contextualised artifact within a socio-technical system.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
cTAKES ("clinical Text Analysis Knowledge Extraction Software") is a natural language processing system for extracting information from electronic medical record clinical free-text, an Apache top level project (TLP) since 2013, developed by the Mayo Clinic and others. It is available under the Apache license. [55]
The first book/manual dedicated to Point and Figure was written by Victor Devilliers in 1933. Chartcraft Inc, in the USA, popularized the system in the 1940s. Cohen founded Chartcraft and wrote on point and figure charting in 1947. Chartcraft published further pioneering books on P&F charting, namely those by Burke, Aby and Zieg.
Seiki Shimizu (清水 正紀, Shimizu Seiki, born 1915 in Japan) is best known for his work as an author writing about Japanese candlestick charting techniques used to analyze and evaluate stocks in his highly regarded book The Japanese Chart of Charts.
The patient's health record is a legal document that contains details regarding patient's care and progress. [3] The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient's healthcare needs, goals, diagnosis and the type of care ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.