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What is the importance of documentation in nursing?

Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.

What is a patient's file?

As proposed, a PATIENT FILE is the section of the electronic health record where information about a single patient is displayed and captured. The display and capture of this information may occur within the PATIENT CHART and within the PATIENT WORKFLOW.

What is a discharge letter from hospital?

A hospital discharge letter is a brief medical summary of your hospital admission and the treatment you received whilst in hospital.It is usually written by one of the ward doctors.

What are examples of medical documents?

What is a medical document? PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy. ... Medical history record. ... Discharge Summary. ... Medical test. ... Mental Status Examination. ... Operative Report.

What are six types of patient files?

Clinical data falls into six major types: Electronic health records. Administrative data. Claims data. Patient / Disease registries. Health surveys. Clinical trials data.

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What are the papers called when you leave the hospital?

A discharge summary plays a crucial role in keeping patients safe after leaving a hospital. As an Advances in Patient Safety report notes, "Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team.

What is documentation in the hospital?

Clinical documentation for hospitals is very important. It is defined as the creation of a digital record that details a medical treatment, clinical test, or medical trial. Clinical documents must be timely, accurate, and outline the specific services that were provided to a patient.

What is meant by documentation in nursing?

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.

What is considered a medical document?

Typically, medical documentation consists of operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, or other notes and/or written documents; it may include ECG/EKG, tracings, images, X-rays, videotapes and other media.

What do you call it when a patient leaves the hospital?

What is hospital discharge? When you leave a hospital after treatment, you go through a process called hospital discharge. A hospital will discharge you when you no longer need to receive inpatient care and can go home.

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What are the papers called when you leave the hospital?

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