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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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 ...

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  4. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    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 ...

  5. Past medical history - Wikipedia

    en.wikipedia.org/wiki/Past_Medical_History

    The Centers for Medicare and Medicaid Services [5] has published criteria for what constitutes a reimbursable PMH. A PMH is considered one of three elements of the "Past, Family, and Social History" (abbreviated as PFSH): [6]

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  7. History of the present illness - Wikipedia

    en.wikipedia.org/wiki/History_of_the_present_illness

    Main page; Contents; Current events; Random article; About Wikipedia; Contact us; Help; Learn to edit; Community portal; Recent changes; Upload file

  8. Olympian Raygun Says She’s Not Fully Retiring from ...

    www.aol.com/olympian-raygun-says-she-not...

    You can’t retire from an art form. So that's why I’m never going to stop,” she said. Related: Australian Breakdance Star Raygun Announces Retirement Over 'Upsetting' Olympic Backlash.

  9. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The CCC System was developed from retrospective research data from 8,967 patient records from a sample of 800 organizations randomly stratified by staff size, type of ownership, and geographic location. [26] The methodology was applied to a national sample of home health agencies that provided all services and products (Spradley & Dorsey, 1985 ...

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