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The system links the U.S. military's 481 medical treatment facilities (MTFs) (including those deployed abroad) to the EHR, ultimately supporting 9.2 million MHS beneficiaries. It is the first system to allow for the central storage of standardized EHR data that is available for worldwide sharing of patient information.
After the conclusion of World War II, U.S. military researchers obtained formulas for the three nerve gases developed by the Nazis—tabun, soman, and sarin.. In 1947, the first steps of planning began when Dr. Alsoph H. Corwin, a professor of chemistry at Johns Hopkins University [4] [5] wrote the Chemical Corps Technical Command positing the potential for the use of specialized enzymes as so ...
SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses.
If a malpractice claim goes to court, through the process of discovery, the prosecution can request a detailed record of all entries made in a patient's electronic record. Waiting to chart patient notes until the end of the day and making addendums to records well after the patient visit can be problematic, in that this practice could result in ...
It states, amongst other things, the statutory duty of medical personnel to document the treatment of the patient in either hard copy or within the electronic patient record (EPR). This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such ...
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]
Rorschach performance assessment system (R-PAS) is a scoring method created by several members of the Rorschach Research Council. They believed that the Exner scoring system was in need of an update, but after Exner's death, the Exner family forbade any changes to be made to the Comprehensive System. [58]
[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 ...