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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 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.
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 ...
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]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
A growing body research suggests your job has a strong impact on your health. ... Work Is the New Doctor's Office. Jamie Ducharme. January 4, 2024 at 1:33 PM. Credit - Illustration by Lon Tweeten ...
Nurse aide (CNA); Nurse technician (CNT); Care partner (CP); Medical Assistants. Certified Medical Assistant (CMA) Certified Medical Assistant - Admin (CMA-A) Certified Medical Assistant - Clinical (CMA-C)
The hospital says it recognises staff need improved facilities for rest during shifts. Skip to main content. 24/7 Help. For premium support please call: 800-290-4726 ...