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Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation. [8] GOLD 2024 defined COPD as a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea or shortness of breath, cough, sputum production or exacerbations) due to abnormalities of the airways (bronchitis ...
Capture patient care data using a standardized coded nursing terminology. Code electronic clinical encounters: diagnoses, interventions, and outcomes. Track nurses' contribution to patient care and care outcomes. Provide standardized concepts (data/elements) for clinical pathways and decision support.
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
A specific program involving exercise, called pulmonary rehabilitation, is proven to help people with COPD. “I can’t recall a patient who didn’t think pulmonary rehabilitation benefited them ...
Obstructive lung disease is a category of respiratory disease characterized by airway obstruction.Many obstructive diseases of the lung result from narrowing (obstruction) of the smaller bronchi and larger bronchioles, often because of excessive contraction of the smooth muscle itself.
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.
After positioning in which the patient sits upright with their arms at the side, with the chest clear of clothing, the four stages of the examination can be carried out. In order to listen to the lungs from the back the patient is asked to move their arms forward to prevent the scapulae (shoulder blades) from obstructing the upper lung fields.
[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 ...