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A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Medical transcription editing is the process of listening to a voice-recorded file and comparing that to the transcribed report of that audio file, correcting errors as needed. Although speech recognition technology has become better at understanding human language, editing is still needed to ensure better accuracy.
A hospital information system ( HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals. In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and ...
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. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...
v. t. e. Case management is a managed care technique within the health care coverage system of the United States. It involves an integrated system that manages the delivery of comprehensive healthcare services for enrolled patients. [1] Case managers are employed in almost every aspect of health care and these employ different approaches in the ...
A standard operating procedure ( SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. [1] SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing miscommunication and failure to comply with industry regulations. [citation needed] Some military ...
Civility – Consensus – Editing Policy – Harassment – Vandalism. Clean Start – Dispute Resolution – Edit Warring – No Personal Attacks – Ownership of Content – Sockpuppetry – Username Policy. Behavioral guidelines. Assume Good Faith – Conflict of Interest – Disruptive Editing – Etiquette – Talk Page Guidelines.
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". [1] Nurses practice in many specialties with ...