Patient Information Management

Publication Date: July 1, 2016

Key takeaways

Clinical documentation should facilitate data capture using a format designed to support clinical workflow activities.

Perioperative nursing documentation must correspond to local, state, and federal regulatory requirements and must incorporate mandatory reporting criteria for quality performance reimbursement.

The health care documentation system must incorporate the standardized clinical terminologies identified by the US government to promote interoperability of health care data.

Structured data collected using a standardized perioperative electronic framework should allow for data aggregation and be extractable for use in research and analytics.

Perioperative documentation must include all patient care orders given in the perioperative patient care setting.

Patient information must be secure, be held confidential and be protected from unauthorized disclosure.

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Overview

Title

Patient Information Management

Authoring Organization

Publication Month/Year

July 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Surgical technologist, nurse, medical techologist technician, healthcare business administration, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D066275 - Health Information Exchange, D063025 - Health Information Management, D019451 - Information Management, D009870 - Operating Room Information Systems

Keywords

hit, healthcare information, information management