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STU3 (Third Standard for Trial Use) [5] included coverage of a variety of clinical workflows, a Resource Description Framework format, and a variety of other updates [7] 2019-10-30: 4.0.1: Release 4 has the First Normative Content and Trial Use Developments [5] [8] 2023-03-26: 5.0.0: Release 5 [5] [9]
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.
A check sheet is a form (document) used to collect data in real time at the location where the data is generated. The data it captures can be quantitative or qualitative. When the information is quantitative, the check sheet is sometimes called a tally sheet. [1] The check sheet is one of the so-called Seven Basic Tools of Quality Control. [2]
A central part of the openEHR specifications is the set of information models, known in openEHR as 'reference models'. [6] The models constitute the base information models for openEHR systems, and define the invariant semantics of the Electronic Health Record (EHR), EHR Extract, and Demographics model, as well as supporting data types, data structures, identifiers and useful design patterns.
The application responding to, i.e., performing, a request for services (orders) or producing an observation.The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
Most electronic health record vendors have adopted the CCD rather than the Continuity of Care Record since it is a newer format that harmonizes the Continuity of Care Record and the HL7 Clinical Document Architecture (CDA) specifications.
Health Level Seven, abbreviated to HL7, is a range of global standards for the transfer of clinical and administrative health data between applications with the aim to improve patient outcomes and health system performance.
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