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A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Facilitates the electronic documentation of patient care at the point of care. Uses a framework of care components to classify the two CCC System terminologies and represent 4 healthcare patterns focusing on a holistic approach to patient care. Consists of flexible, adaptable, and expandable concepts/data elements.
The patient's health record is a legal document that contains details regarding patient's care and progress. [3] The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient's healthcare needs, goals, diagnosis and the type of care ...
In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
primary care physician (also called primary care provider) PCR: patient care report polymerase chain reaction: PCS: post-concussion syndrome: PCT: progesterone challenge test Patient care technician: PCV: packed cell volume (see hematocrit) polycythemia vera: PCWP: pulmonary capillary wedge pressure: PD: Parkinson's disease paroxysmal ...
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient.Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence.
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The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. [13]