Ad
related to: definition of patient information in nursing practice
Search results
Results From The WOW.Com Content Network
It makes the process of nursing assessment visible through what is presented in the documentation content. [4] During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5]
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The partnership of nursing and technology is vital for designing nursing practice environments. [32] The benefit of the CCC is the ability to represent the essence of nursing care in health information systems and applications during any patient care, transfer or transition.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
The practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as accountability mechanisms. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.
It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with electronic health records (EHRs).
One of the federal laws enacted to safeguard patient's health information (medical record, billing information, treatment plan, etc.) and to guarantee patient's privacy is the Health Insurance Portability and Accountability Act of 1996 or HIPAA. [109] HIPAA gives patients the autonomy and control over their own health records. [109]