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The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [ 8 ]
[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 ...
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
A court reporter, court stenographer, or shorthand reporter [1] is a person whose occupation is to capture the live testimony in proceedings using a stenographic machine or a stenomask, thereby transforming the proceedings into an official certified transcript by nature of their training, certification, and usually licensure.
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]
The quality of the scientific reporting of case reports is variable, and sub-optimal reporting hinders the use of case reports to inform research design or help guide clinical practice. [4] In response to these issues, reporting guidelines are under development to facilitate greater transparency and completeness in the provision of relevant ...
Evidence packaging involves the specialized packaging methods and materials used for physical evidence. Items need to be collected at a crime scene or a fire scene, forwarded to a laboratory for forensic analysis , put in secure storage, and used in a courtroom, all while maintaining the chain of custody .
The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1] The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings ...