Health & Medical Health Care

What Is Clinical Documentation?

Clinical documentation improvement program is an electronic way of listing of clinical problems and other aspects.
Doctors and nurses create and update the list of clinical problems of patients in order to focus and coordinate interventions, all caregivers in the hospital and throughout the continuum of care health, list of clinical problems based on the standardized terminology SNOMED CMLC, support for the resolution and reactivation problems and complete online history of updates and revisions.
Data on allergies are visible and accessible at any time by clinicians.
The user is constantly informed of the allergies that the patient suffers and those active at the time he reaches his record.
The advantages of the Clinical documentation improvement program are quick and easy access to data using "smart fields" Oacis, list of common allergy for quick, list of allergens based on data FDBMC (First Databank) and possibility to include an approximate date of onset of symptoms.
The Clinical documentation improvement program performs automatic entry of the date, time and coordinates the user at each entrance to form a detailed audit trail.
This provides an opportunity to complete an online registry of revisions that results in updates or changes made by users in the modules.
These can be made on the Notes, Allergies, Problem List, and clinical history and on medication and immunization.
This is very professional and is used to help users to document clinical information.
These standards facilitate the review of clinical results, variances and trends emerging in the clinical data.
The key benefits of the Clinical documentation improvement program are listed below: Consolidates data from disparate applications, contributes to compliance with the guidelines and standards, provide flexibility for specialized needs, support the flow of clinical care, process the communication between clinicians, increases patient safety, improve clinical outcomes, robust clinical data repository, pricing models predefined, predefined templates for monitoring entrances and exits of liquids excretion and ingestion, list of predefined clinical problems based on SNOMED CMLC and finally the predefined lists based on common allergic reactions.
The clinical documentation improvement program produces a dynamic relationship in order to compare scores in time and thus be described, stored and printed in multiple copies and filed with the tribunal, the patient record and researchers.
As the only developer, they had contributed to the analysis of the system, the data architecture, the establishment of the database and the definition of XML structures.
So does the development of Web technology and is implementing several Web services to allow connections to systems houses to collect and interface socio-demographic information of patients, the list of episodes of care, the history Omega scores, diagnoses related to the episode of care desired so that the list of patients per group involved (cohort), in addition to validating the authentication link.
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