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The systematic review of nursing documentation audit studies in different settings [19] identified the following relevant quality characteristics of nursing documentation: Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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]
They may work in a broad range of settings that span the continuum of healthcare including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. Health information managers may specialize in registry management, data management, and data quality among other areas.
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The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings. [2] Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care.
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