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SOAP note. 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 record is an integral part of practice ...
Electronic health records flow chart. Clinical Data Repository/Health Data Repository (CDHR) is a database that allows for the sharing of patient records, especially allergy and pharmaceutical information, between the Department of Veteran Affairs (VA) and the Department of Defense (DoD) in the United States.
Clinical decision support system. A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Medical scribe. A medical scribe is an allied health paraprofessional who specializes in charting physician - patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the ...
The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. [1] According to the model, information about quality of care can be drawn from three categories: “structure,” “process,” and “outcomes." [2] Structure describes the context in which care is ...
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]
Cleveland Clinic Akron General, formerly known as Akron General Medical Center, and commonly known as Akron Gen, is a nationally ranked, 511-bed non-profit, teaching hospital located in Akron, Ohio. [82] In August 2015, the Akron General Health System joined the Cleveland Clinic Health System.
A medical laboratory or clinical laboratory is a laboratory where tests are conducted out on clinical specimens to obtain information about the health of a patient to aid in diagnosis, treatment, and prevention of disease. [1] Clinical medical laboratories are an example of applied science, as opposed to research laboratories that focus on ...
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