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The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Medical education applies theories of pedagogy specifically in the context of medical education. Medical education has been a leader in the field of evidence-based education, through the development of evidence syntheses such as the Best Evidence Medical Education collection, formed in 1999, which aimed to "move from opinion-based education to evidence-based education". [2]
A medical writer, also referred to as medical communicator, [1] is a person who applies the principles of clinical research in developing clinical trial documents that effectively and clearly describe research results, product use, and other medical information. The medical writer develops any of the five modules of the Common Technical ...
Training in evidence based medicine is offered across the continuum of medical education. [58] Educational competencies have been created for the education of health care professionals. [111] [58] [112] The Berlin questionnaire and the Fresno Test [113] [114] are validated instruments for assessing the effectiveness of education in evidence ...
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Nursing Education Applications: Teach students how to electronically document and code POCs based on the nursing process. Track student assignments: procedures and protocols. Test and evaluate online the clinical documentation of student's patient care. Teach and evaluate student use of simulations. Use Second Life to enhance educational ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]