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  2. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS). Sections of MDS (Minimum Data Set): Identification Information; Hearing, Speech and Vision

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    An example of a nursing care plan in an Australian residential aged care home. Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing ...

  4. 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 ...

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    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 required anywhere from several times an hour to several times a day.

  6. Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Clinical_Document_Architecture

    An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [ 3 ] It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.

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  9. Clinical Care Classification System - Wikipedia

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

    A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.

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