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  2. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

  3. List of hospitals in Massachusetts - Wikipedia

    en.wikipedia.org/wiki/List_of_hospitals_in...

    Map all coordinates in "Category:Hospitals in Massachusetts" using OpenStreetMap Download coordinates as: KML GPX (all coordinates) GPX (primary coordinates) GPX (secondary coordinates) This is a list of current and former hospitals in the Commonwealth of Massachusetts, U.S. By default, the list is sorted alphabetically by name. This table also provides the hospital network of each hospital ...

  4. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    Participants in the assessment process are health care professionals and direct care staff such as registered nurses, licensed practical or vocational nurses (LPN/LVN), Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. 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.

  6. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.

  7. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [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 ...

  8. Adoption of electronic medical records in U.S. hospitals

    en.wikipedia.org/wiki/Adoption_of_Electronic...

    The EMR Adoption Model shows that in 2011, the number of acute care hospitals achieving Stage 5 or Stage 6 increased by more than 80 percent. [4] Meanwhile, the number of hospitals at Stages 0, 1, 2, and 3 has decreased. Furthermore, adoption has increased most among large hospitals and those in urban areas. [3] [clarification needed]

  9. Continuity of Care Record - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Record

    Continuity of Care Record (CCR) [1] is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.