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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 ...
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...
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]
Long-term care can be provided formally or informally. Facilities that offer formal LTC services typically provide living accommodation for people who require on-site delivery of around-the-clock supervised care, including professional health services, personal care, and services such as meals, laundry and housekeeping. [4]
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
UAPs working in long-term care are much more likely to experience workplace violence than UAPs working in hospitals. [30] In a given year, 34% of American UAPs in long-term care facilities experience physical injury, including human bites, after a resident assaults them. [31] The COVID-19 pandemic also contributed to UAPs leaving the job in ...
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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 ...
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