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Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare.
In the United States, mid-level practitioners are health care workers with training less than that of a physician but greater than that of nurses or medical assistants. The term mid-level practitioner or mid-level provider is related to the occupational closure of healthcare.
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
A medical assistant, also known as a "clinical assistant" or healthcare assistant in the US, [1] is an allied health professional who supports the work of physicians, nurse practitioners, physician assistants and other health professionals, usually in a clinic setting. Medical assistants can become certified through an accredited program.
Most UAPs, including nursing assistants, are not certified to change sterile dressings, distribute medications, insert or remove any tubing (such as nasogastric tubes), or conduct tube feedings. Such tasks should be therefore left to the overseeing nurse or clinical licensed professional. [4] UAPs must be delegated responsibilities.
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care.