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Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. [9] Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting.
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
This documentation must also include the medical report and must be archived by the attending physician for at least 10 years. The law clearly states that these records are not only memory aids for the physicians, but also should be kept for the patient and must be presented on request.
These documents must be capable of including data elements known as the "Common MU Data Set" that include: Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions ...
Each of these may include quantities or frequencies, and responses to CAGE questions may be reported. May also include information about travel and occupation. May also include sexual history, though this may be split off in a separate section. physical exam: see Physical examination#Example: see Physical examination#Example: labs and ...
This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results, and any other data from ancillary services or provider notes. [67] This type of event monitoring has been implemented using the Louisiana Public Health Information Exchange, which links statewide public health with electronic medical records.
President Donald Trump’s executive order grasping far greater control over independent federal agencies embraces a constitutionally questionable theory that presidents dating back to Ronald ...
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.
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