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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
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. [1]
The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...
Under Canadian federal law, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves. [29] The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records.
The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
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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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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