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Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare.
In the United States, mid-level practitioners are health care workers with training less than that of a physician but greater than that of nurses or medical assistants. The term mid-level practitioner or mid-level provider is related to the occupational closure of healthcare.
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
Most UAPs, including nursing assistants, are not certified to change sterile dressings, distribute medications, insert or remove any tubing (such as nasogastric tubes), or conduct tube feedings. Such tasks should be therefore left to the overseeing nurse or clinical licensed professional. [4] UAPs must be delegated responsibilities.
A medical assistant, also known as a "clinical assistant" or healthcare assistant in the US, [1] is an allied health professional who supports the work of physicians, nurse practitioners, physician assistants and other health professionals, usually in a clinic setting. Medical assistants can become certified through an accredited program.
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.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...