Search results
Oct 29, 2020 · Objective. Healthcare systems have adopted electronic health records (EHRs) to support clinical care. Providing patient-centered care (PCC) is a goal of many healthcare systems. In this study, we sought to explore how existing EHR systems support PCC; defined as understanding the patient as a whole person, building relational connections ...
Oct 19, 2016 · Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Regardless of the form of the records ( i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals.
- Alexander Mathioudakis, Ilona Rousalova, Ane Aamli Gagnat, Neil Saad, Georgia Hardavella
- 2016
People also ask
Are clinical records confidential?
Why are clinical records regulated?
How to maintain confidential work-related healthcare personnel health records?
A health record (also known as a medical record) is a written account of a person’s health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
- Narrative Notes. Narrative nurses notes are like a running log of everything that happened with the patient during a particular shift. The benefits of narrative notes are that they’re straightforward, easy to do, and simple to follow.
- Charting by Exception. Instead of comprehensive note-taking, charting by exception (CBE) documents only things that are outside the norm. The beauty of CBE is that it takes significantly less time to do, giving nurses more time to focus on other tasks.
- SOAP(IER) Notes. SOAP(IER) stands for “subjective,” “objective,” “assessment,” and “plan,” with some nurses choosing also to add “intervention,” “evaluation,” and “revision.”
- PIE Charting. Similar to SOAP(IER), PIE is a simple acronym you can use to document specific problems (P), as well as their related interventions (I) and evaluations (E).
Oct 17, 2022 · A personal health record (PHR) refers to the collection of an individual's medical documentation maintained by the individual themselves, or a caregiver, in cases where patients are unable to do so themselves. This personal information includes details such as: The patient's medical history. Applicable diagnoses.
May 11, 2023 · A medical record is a written account of a person's health history. Today, most medical records are kept and shared electronically, although some providers will maintain paper records. Your medical records may include: Information about your past history, family history, and social history. Records of diagnoses, including provisional diagnoses.
Maintain healthcare personnel records and databases that include medical evaluations, infectious disease screening, evidence of immunity and immunizations, exposure and illness management, and work restrictions.
