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V3DAM DCM4MEDDEV R1 O1 2010SEP Detailed Clinical Model for Medical Devices Draft for Comment Universal Realm First Ballot: September 2010 2009 Health Level Seven, Inc. Ann Arbor, MI All rights reserved.
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How to Fill Out Detailed Clinical Model for:

01
Start by gathering the necessary information: Before filling out the detailed clinical model, gather all the relevant patient information including medical history, current medications, allergies, and any other pertinent details.
02
Use standardized terminology: In order to ensure accurate and consistent documentation, utilize standardized terminology like SNOMED CT or LOINC to describe clinical concepts and findings.
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Capture comprehensive patient assessment: Document detailed information about the patient's physical examination, laboratory test results, and diagnostic procedures. Include any subjective and objective data that can contribute to a holistic understanding of the patient's condition.
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Include problem lists: Enumerate the patient's primary and secondary medical issues. Provide a clear and concise description of each problem, along with any associated details or complications.
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Describe interventions and management plans: Outline the specific interventions and treatment plans for each identified problem or condition. This includes medications, therapies, procedures, and other recommended actions to address the patient's health concerns.
06
Record progress notes: Regularly update the detailed clinical model with progress notes to document the patient's response to treatment, any changes in their condition, and modifications to the management plan. This ensures a comprehensive timeline of the patient's medical journey.

Who Needs Detailed Clinical Model for:

01
Physicians and healthcare professionals: Detailed clinical models are primarily used by physicians and healthcare professionals to effectively document and communicate patient information across different healthcare settings. It provides a standardized format for comprehensive clinical assessment and enhances the exchange of medical data.
02
Clinical researchers: Detailed clinical models are also valuable for clinical researchers analyzing patient data and conducting studies. By utilizing a structured and uniform model, researchers can easily compare and analyze data from multiple sources, leading to more robust and meaningful research outcomes.
03
Health IT developers and system vendors: Health IT developers and system vendors utilize detailed clinical models to design and develop electronic health record systems, clinical decision support tools, and other health information technologies. These models serve as the foundation for building interoperable and efficient healthcare systems.
In conclusion, filling out a detailed clinical model requires gathering comprehensive patient information, using standardized terminology, documenting assessment findings, managing problem lists, describing interventions, and updating progress notes. It is an essential tool for physicians, clinical researchers, and health IT developers aiming to improve patient care, research outcomes, and healthcare system interoperability.
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