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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 personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
Nursing care plans provide continuity of care, safety, quality care and compliance. 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 ...
Person-centered care. In health care, person-centered care is a practice in which patients actively participate in their own medical treatment in close cooperation with their health professionals. Sometimes, relatives may be involved in the creation of the patient’s health plan. [1] The person-centered model of health care is used both for in ...
Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
A patient tracking system (also called patient identification system) allows a healthcare provider to log and monitor the progress of a person through the provision of care during their stay there. Such systems are part of an overall information system and may interact with the person's electronic health record, [1] where information specific ...
Continuity of Care Record ( CCR) [1] is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health ...
The Patient Activation Measure is being used in a number of ways to improve the delivery of health care, including: a metric to assess the degree to which patients are prepared and able to self-manage; to tailor support and education to help patients increase in activation
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