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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]
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
Barcode technology can help prevent medical errors by making accurate and reliable information readily available at the point-of-care. Information, such as the drug identification, medication management, infusion safety, specimen collection, etc. and any other patient care activity can be easily tracked during the patient stay.
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
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In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording. [152]