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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 ...
Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology; An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [3]
Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or have severe physical trauma .
A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]
East Lancashire Hospitals NHS Trust is an NHS hospital trust in Lancashire, England. It was established on 1 September 2002, [2] as the result of a locally controversial, cost saving merger of Blackburn Hyndburn & Ribble Valley NHS Trust and Burnley Health Care NHS Trust, first announced in September 1999. [3] Shazad Sarwar was appointed chair ...
When ambulatory and inpatient care providers attest that they have achieved the first stage of meaningful use, they document that they have tested their capability to "exchange clinical information and patient summary record", which is a core objective of the program. [8]
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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]