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[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
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Regulations concerning fabrication or forgery of medical certificates vary by jurisdiction, but users of falsified medical certificates may face legal and health consequences. [15] In New South Wales, medical professionals who "deliberately issue a false, misleading or inaccurate certificate" can be charged under the Medical Practice Act. [16]
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