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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 ...
A printed, optical, or electronic document designed to record all of the protocol-required information to be reported to the sponsor on each trial subject. (ICH E6) Case series A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
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.
The standard treatment, also known as the standard of care, is the medical treatment that is normally provided to people with a given condition. In many scientific studies, the control group receives the standard treatment rather than a placebo while a treatment group receives the experimental treatment. [ 1 ]
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
What addicts face is a revolving door, an ongoing cycle of waiting for treatment, getting treatment, dropping out, relapsing and then waiting and returning for more. Like so many others, Tabatha Roland, the 24-year-old addict from Burlington, wanted to get sober but felt she had hit a wall with treatment.
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 ...