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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    These documents record the client's data captured at the relevant stages of the nursing process. [2] The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential aged care homes.

  3. Advance healthcare directive - Wikipedia

    en.wikipedia.org/wiki/Advance_healthcare_directive

    An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a ...

  4. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. 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.

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections.

  6. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    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 ...

  7. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

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  9. Medical encyclopedia - Wikipedia

    en.wikipedia.org/wiki/Medical_encyclopedia

    A medical encyclopaedia is a comprehensive written compendium that holds information about diseases, medical conditions, tests, symptoms, injuries, and surgeries. It may contain an extensive gallery of medicine-related photographs and illustrations. [1] A medical encyclopaedia provides information to readers about health questions. It may also ...

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