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  2. 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 ...

  3. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    Care Area Assessment (CAA) Summary; Correction Request; Assessment Administration; The MDS is updated by the Centers for Medicare and Medicaid Services. Specific coding regulations in completing the MDS can be found in the Resident Assessment Instrument User's Guide. Versions of the Minimum Data Set has been used or is being utilized in other ...

  4. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.

  5. Clinical pathway - Wikipedia

    en.wikipedia.org/wiki/Clinical_pathway

    A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).

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  7. Roper–Logan–Tierney model of nursing - Wikipedia

    en.wikipedia.org/wiki/Roper–Logan–Tierney...

    These activities, outlining both the norm for the patient as well as any changes that may have resulted from current changes in condition, are assessed on admission onto a ward or service, and are reviewed as the patient progresses and as the care plan evolves. To provide effective care, all of the patient's needs (which are determined by ...

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  9. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    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 ...