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Patient safety work product includes any data, reports, records, memoranda, analyses (such as root cause analyses), or written or oral statements (or copies of any of this material), which are assembled or developed by a provider for reporting to a PSO and are reported to a PSO; or are developed by a patient safety organization for the conduct ...
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 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 ...
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.
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
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]
A medical doctor explaining an X-ray to a patient. Several factors help increase patient participation, including understandable and individual adapted information, education for the patient and healthcare provider, sufficient time for the interaction, processes that provide the opportunity for the patient to be involved in decision-making, a positive attitude from the healthcare provider ...
The Act covers the following subjects relating to personal health information in the province of Ontario: Section 1: Interpretation and Application sets out of the purpose of the Act. It defines key terms used throughout the Act, such as "health information custodian" and "health information agent".