کد مقاله | کد نشریه | سال انتشار | مقاله انگلیسی | نسخه تمام متن |
---|---|---|---|---|
5567112 | 1403612 | 2016 | 12 صفحه PDF | دانلود رایگان |
عنوان انگلیسی مقاله ISI
Guideline Implementation: Patient Information Management
ترجمه فارسی عنوان
پیاده سازی دستورالعمل: مدیریت اطلاعات بیمار
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کلمات کلیدی
موضوعات مرتبط
علوم پزشکی و سلامت
پرستاری و مشاغل بهداشتی
پرستاری
چکیده انگلیسی
Clinical documentation captured in a patient's record provides health care personnel with information that can be used to guide patient care. Data collected in electronic health records can be accessed and aggregated across the health care delivery system to enhance the safety, quality, and efficacy of care. The updated AORN “Guideline for patient information management” provides guidance to perioperative personnel on documenting and managing patient information. This article focuses on key points of the guideline, which address data capture that supports the clinical workflow, incorporation of professional guidelines and standards as well as regulatory and mandatory reporting elements, use of standardized clinical terminologies, data aggregation for use in research and analytics, considerations for patient care orders, and safeguards for the patient's security and confidentiality. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.
ناشر
Database: Elsevier - ScienceDirect (ساینس دایرکت)
Journal: AORN Journal - Volume 104, Issue 6, December 2016, Pages 566-577
Journal: AORN Journal - Volume 104, Issue 6, December 2016, Pages 566-577
نویسندگان
Jennifer L. DNP, RN, CNS, CNOR,