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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.
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. [1] 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.
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 informatics vendors.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Medical standards of care exist for many conditions, including diabetes, [3] some cancers, [4] and sexual abuse. [5] Failure to provide patients treatment that meets a standard of care can incur legal liability for any injury or death that results. In large-scale disasters, public authorities may declare crisis standards of care apply. This ...
Vitas “regularly ignored concerns expressed by its own physicians and nurses regarding whether its hospice patients were receiving appropriate care,” the lawsuit alleges. Prosecutors claim the fraud didn’t just occur in that past, but that it is ongoing, with the knowledge of executives at both Vitas and Chemed Corp., the company’s parent.
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
A 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University concluded that the U.S. treatment system is in need of a “significant overhaul” and questioned whether the country’s “low levels of care that addiction patients usually do receive constitutes a form of medical malpractice.”
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