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The Nursing Outcomes Classification (NOC) is a classification system which describes client outcomes sensitive to nursing intervention. The Omaha System : The Omaha System is a standardized health care terminology consisting of an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records.The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use ...
An example of an application of informatics in medicine is bioimage informatics. Dutch former professor of medical informatics Jan van Bemmel has described medical informatics as the theoretical and practical aspects of information processing and communication based on knowledge and experience derived from processes in medicine and health care. [2]
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Medical audit later evolved into clinical audit and a revised definition was announced by the NHS Executive: "Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."
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