What are the types of clinical documentation?
Table of Contents
What are the types of clinical documentation?
What Is Clinical Documentation in a Patient’s Record?
- Attending Physician Documentation.
- History and Physical.
- Progress Notes.
- Orders.
- Procedure Reports (Attending Surgeon)
- Discharge Summary.
- Other Physician Documentation.
- Consultation Reports.
What is the computerized documentation?
Computer Documentation means the technical documentation pertaining to the any software included in the Assets including, without limitation, any end-user manuals, product specifications, algorithms, diagrams, bug lists, and electronic machine readable versions of such manuals, product answer books and other related …
What are six types of patient files?
What is a medical document?
- PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy.
- Medical history record.
- Discharge Summary.
- Medical test.
- Mental Status Examination.
- Operative Report.
What are the different types of electronic medical records?
EMR Software
- Cloud-Based EMR Software. A cloud-based EMR software allows data to be accessed online.
- Mac EMR Software. Mac EMR software, as can be assumed by the name, includes software compatible with all Apple devices.
- ONC-Certified EMR Software.
- Behavioral/Mental Health EMR Software.
- Medical Billing Software.
What are different types of records?
Types of Records
- I. Administrative Records. Records which pertain to the origin, development, activities, and accomplishments of the agency.
- II. Legal Records.
- III. Fiscal Records.
- IV. Historical Records.
- V. Research Records.
- VI. Electronic Records.
What computer systems are used in hospitals?
Allscripts, Epic, Cerner, McKesson and Quadramed are the most popular EHR systems among academic medical centers, teaching facilities and hospitals with more than 300 beds, according to a report from KLAS.
What are 4 components of correct nursing documentation?
For documentation to support the delivery of safe, high-quality care, it should: Be clear, legible, concise, contemporaneous, progressive and accurate.
What are the best practices for nursing documentation?
Understand nursing practice acts. The healthcare industry and the practice of nursing are heavily regulated by both federal and state laws.
What are the applications of computers in nursing?
such as email, computers have many other applications in nursing. Nursing Administration: Computers are used in the administrative areas of nursing for basic tasks that once were done on paper.
How are computers used in the nursing profession?
Alex Mihailidis,Peng Laura Krones and Jennifer Boger Masc (2006).
What is the purpose of documentation in nursing?
Purpose of Nursing Documentation. The primary purpose of documentation of client care is the communication among health care professional to promote continuity of care among departments throughout 24 hours.
