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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.
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]
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 ...
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are ...
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
Other choices for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case ...
A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]
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