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The plan is what the health care provider will do to treat the patient's concerns—such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. [14] The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters.
The patient summary contains 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. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...
Patients were listed according to the procedures they were having done, which determined their plan of care. [5] Care provided was passed on by word of mouth, dressing books, and work lists. [ 5 ] These forms of communication all focus on activities the nurse performed instead of focusing on the patient. [ 5 ]
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
Some patient portal applications enable patients to register and complete forms online, which can streamline visits to clinics and hospitals. Many portal applications also enable patients to request prescription refills online, order eyeglasses and contact lenses, access medical records, pay bills, review lab results, and schedule medical ...
Patient check-in is the process where patients begin their registration with the healthcare facility topically using a clipboard, electronic tablet, touch screen, kiosk, or by other method, sometimes self-service. Patient check-in start as far back as the Roman times when patients would wait for special services in purpose-built hospitals.
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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]
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