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Electronic documentation. Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the ...
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. Nursing documentation is the principal clinical information source to meet legal ...
MeSH. D000067716. Point-of-care testing ( POCT ), also called near-patient testing or bedside testing, is defined as medical diagnostic testing at or near the point of care —that is, at the time and place of patient care. [1] [2] This contrasts with the historical pattern in which testing was wholly or mostly confined to the medical ...
Policies and activities COVID-19 pandemic. California has the only legislatively mandated nurse-to-patient ratios in the country. In December 2020, during the fall/winter COVID-19 pandemic surge, governor Gavin Newsom gave all hospitals a temporary waiver from those mandates, which allowed hospitals, for example, to have ICU nurses care for three patients rather than two.
e. Unlicensed assistive personnel ( UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). UAPs also provide bedside care—including basic nursing procedures—all under the supervision of a registered nurse, licensed practical ...
The Minimum Data Set ( MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term "swing bed" refers to the Social Security Act's authorizing small, rural hospitals to use their beds ...
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 ...
Continuity of Care Document. 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. [1]