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Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0.
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...
[[Category:Hospital templates]] to the <includeonly> section at the bottom of that page. Otherwise, add <noinclude>[[Category:Hospital templates]]</noinclude> to the end of the template code, making sure it starts on the same line as the code's last character.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Infobox for hospitals, worldwide from large to small. Formats a right-side infobox to display many data items about a hospital, with the typical labels listed down the left side, and the corresponding data values on the right side of the box. Template parameters This template prefers block formatting of parameters. Parameter Description Type Status Name name Name The hospital name. When not ...
Providing patients with information is central to patient-centered health care and this has been shown to have some positive effects on health outcomes. [20] Providing patients with access to their health records including medical histories and test results via an electronic health record is a legal right in some parts of the world. [20]
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