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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Oracle Health, formerly Cerner Corporation then Oracle Cerner, is a US-based, multinational provider of health information technology (HIT) platforms and services. As of February 2018 [update] , it had 27,000 customers globally [ 3 ] and 29,000 employees, with over 13,000 at its headquarters in North Kansas City, Missouri .
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
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Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, [1] and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. [2]
All Cerner Millennium health information technology software uses CCL/Discern Explorer to select from, insert into, update into and delete from a Cerner Millennium database and allows a programmer to fetch data from an Oracle database and display it as the user wants to see. With features like Record Structure and subroutines it allows a user ...
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.
An example of an application of informatics in medicine is bioimage informatics.. Dutch former professor of medical informatics Jan van Bemmel has described medical informatics as the theoretical and practical aspects of information processing and communication based on knowledge and experience derived from processes in medicine and health care.