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  2. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems. Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated.

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6] The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure ...

  4. Forms processing - Wikipedia

    en.wikipedia.org/wiki/Forms_processing

    Forms processing is a process by which one can capture information entered into data fields and convert it into an electronic format. This can be done manually or automatically, but the general process is that hard copy data is filled out by humans and then "captured" from their respective fields and entered into a database or other electronic format.

  5. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Analysis: the process of translating data into information utilized for an application. Each aspect is analyzed with 10 different data characteristics: Accuracy: Data are the correct values and are valid. Accessibility: Data items should be easily obtainable and legal to collect. Comprehensiveness: All required data items are included. Ensure ...

  6. Case report form - Wikipedia

    en.wikipedia.org/wiki/Case_report_form

    A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.

  7. Nursing Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Nursing_Minimum_Data_Set

    The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...

  8. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the nursing process: Assessment; Diagnosis

  9. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    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.