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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.
Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice. In Nursing, as in other professions, peer review applies professional control to practice, and is used by ...
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
Medical privacy, or health privacy, is the practice of maintaining the security and confidentiality of patient records. It involves both the conversational discretion of health care providers and the security of medical records.
A nurse in Indonesia examining a patient A nurse treating a patient with burns, Ziguinchor PAIGC hospital, 1973. 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 ...
The Patient Self-Determination Act (PSDA) was passed by the United States Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990.Effective on December 1, 1991, this legislation required many hospitals, nursing homes, home health agencies, hospice providers, health maintenance organizations (HMOs), and other health care institutions to provide information about ...
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 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.