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A nursing care plan provides direction on the type of nursing care the individual/family/community may need. [1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. [2]
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice ...
The HL7 Consolidated Clinical Document Architecture (C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1][2][3] All certified Electronic health records in the United States are required to export medical data using the C-CDA standard. [4] While ...
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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.
Clinical Care Classification System. The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.
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The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and colloquially as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare ...