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Continuity of Care Document. The Continuity of Care Document (CCD) specification is an XML -based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. [1]
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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The SOAP note(an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. [1][2]Documenting patient encounters in the medical recordis an integral part of practice workflow starting ...
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]
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
A medical certificate or doctor's certificate[1][2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note (UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.
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 ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).