Clinical note definition

Clinical note means a dated, written notation by a member of the health team which indicates contact with a patient and describes any of the following: signs and symptoms of dysfunction, treatment given or medication administered, the patient's reaction, changes in physical or emotional condition, or services provided.

Clinical note means a dated written notation of contact with a patient by a member of a health care team, which contains a description of signs and symptoms, treatment or drugs given, the patient’s reaction and any changes in physical or emotional condi- tion.

Clinical note means a written notation of a healthcare contact with a consumer that is signed, with date and time, by an employee of the home care agency that describes signs and symptoms; treatment; education; drugs administered and the consumer’s reaction; and any changes in physical or emotional condition.

Examples of Clinical note in a sentence

• Clinical note in physician record states that patient called primary care physician (PCP) on January 30th stating that the wound has gotten larger and there is copious purulent drainage causing the dressing to be saturated.

• Clinical note means a notation of a contact with a patient that is written and dated by a member of the health team, and that describes signs and symptoms, treatment and drugs administered and the patient's reaction, and any changes in physical or emotional condition.

• This certificate must be accompanied by a brief resume of the case giving the nature of the illness, its symptoms, causes and duration.APPENDIX-3 FORMAT FOR MEDICAL RECORD(see regulation 3.1) Name of the patient : Age : Sex : Address : Occupation : Date of 1st visit : Clinical note (summary) of the case : Prov.

• Clinical note that documents:a) individual(s) present in sessionb) focus of the session (i.e., alleviation of the emotional disturbances, reversal or change of maladaptive patterns of behavior)c) treatment goal(s) addressed in the sessiond) client’s progress or if no progress documentation or reasons/barriers6.

• APPENDIX-3 FORMAT FOR MEDICAL RECORD (see regulation 3.1) Name of the patient : Age : Sex : Address : Occupation : Date of 1st visit : Clinical note (summary) of the case: Prov : Diagnosis :Investigations advised with reports: Diagnosis after investigation: Advice :Follow upDate: Observations: Signature in full...................Name of Treating Physician APPENDIX -4 LIST OF CERTIFICATES, REPORTS, NOTIFICATIONS ETC.

More Definitions of Clinical note

Clinical note means a written notation, dated and signed by the appropriate member of the health team, of a contact with a patient, containing a description of signs and symptoms, treatment and/or drugs given, the patient's reaction and any changes in physical or emotional condition. Clinical notes are written on the day service is rendered and incorporated into the patient's clinical records at least weekly.

Clinical note means a written statement contained within a patient=s home care record, dated and signed by the person delivering the care, treatment or service, describing the treatment or services delivered and the effect of the care, treatment or services on the patient=s medical condition.

Clinical note means a dated and signed written notation by the providing member of the health team of a contact with a patient containing a description of signs and symptoms, treatment and drug given, the patient's reaction, and any changes in physical or emotional condition.

Clinical note means a dated and signed notation, with service designation by a member of the health team, of a contact with a patient.

Clinical note means a written statement contained within a client’s home care record, dated

Clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient's reaction and/or response, and any changes in physical, emotional, psychosocial or spiritual condition during a given period of time.

Clinical note means a notation of a contact with a patient that is written and dated by a member of the health care team and that describes signs and symptoms, treatment and drugs administered and the patient's reaction, and any changes in physical or emotional condition.