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2. History of the present illness - Wikipedia

   en.wikipedia.org/wiki/History_of_the_present_illness

   Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).

3. Medical history - Wikipedia

   en.wikipedia.org/wiki/Medical_history

   The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...

4. SBAR - Wikipedia

   en.wikipedia.org/wiki/SBAR

   SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses.

5. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   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 ...

6. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   A written record of the history, treatment, care, and response of the client while under the care of a health care provider. A guide for reimbursement of care costs. Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process.

7. Minimum Data Set - Wikipedia

   en.wikipedia.org/wiki/Minimum_Data_Set

   Participants in the assessment process are health care professionals and direct care staff such as registered nurses, licensed practical or vocational nurses (LPN/LVN), Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in ...

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   mail.aol.com

   Get AOL Mail for FREE! Manage your email like never before with travel, photo & document views. Personalize your inbox with themes & tabs. You've Got Mail!

9. Electronic health record - Wikipedia

   en.wikipedia.org/wiki/Electronic_health_record

   Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.