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In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTM's Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards. [citation needed]
The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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.
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
When electronically produced, the documentation must be checked for accuracy [1] [page needed] Free from errors [2] [5] For some types of data, it is recommended that records are in a format that permits trend evaluation [6]
Historically, most classes of technical documentation lacked universal conformity for format, content and structure. Standards are being developed to redress this through bodies such as the International Organization for Standardization(ISO), which has published standards relating to rules for preparation of user guides, manuals, product specifications, etc. for technical product documentation.
These types of documents define how a specific document should be written, which may include, but is not limited to, the systems of a document naming, version, layout, referencing, structuring, appearance, language, copyright, hierarchy or format, etc. [34] [35] Very often, this kind of specifications is complemented by a designated template.