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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. Nursing documentation is the principal clinical information source to meet legal ...
Oracle Health, formerly Cerner Corporation then Oracle Cerner, is a US-based, multinational provider of health information technology (HIT) platforms and services. As of February 2018 [update] , it had 27,000 customers globally [ 3 ] and 29,000 employees, with over 13,000 at its headquarters in North Kansas City, Missouri .
CBT proposes four assumptions essential to the approach to treatment: addiction is a learned behavior, it emerges in an environmental context, it is developed and maintained by particular thought patterns and processes, and CBT can be integrated well with other treatment and management approaches as they all have similar goals. [17]
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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
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 ...
A drug-therapy (related) problem can be defined as an event or circumstance involving drug treatment (pharmacotherapy) that interferes with the optimal provision of medical care. In 1990, L.M. Strand and her colleagues (based on the previous work of R.L Mikeal [ 3 ] and D.C Brodie, [ 4 ] published respectively in 1975 and 1980) classified the ...
An EMR includes the medical and treatment history of patients treated by that specific practice. [ 9 ] In contrast, a personal health record (PHR) is an electronic application for recording personal medical data that the individual patient controls and may make available to health providers.