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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 ...
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 ...
Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, [1] and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. [2]
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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 .
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
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.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...