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Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. [ 1 ]
A check sheet is a form (document) used to collect data in real time at the location where the data is generated. The data it captures can be quantitative or qualitative. When the information is quantitative, the check sheet is sometimes called a tally sheet. [1] The check sheet is one of the so-called Seven Basic Tools of Quality Control. [2]
A Medication Administration Record [1] (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical chart. The health care ...
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 ...
As stated in a 2006 Institute of Medicine (IOM) report, "HEDIS measures focus largely on processes of care"; [14] the strengths of process measures include the facts that they "reflect care that patients actually receive," thereby leading to "buy-in from providers," and that they are "directly actionable for quality improvement activities" [14 ...
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