Patient Information Management
Publication Date: July 1, 2016
Last Updated: March 14, 2022
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
Association of periOperative Registered Nurses
Publication Month/Year
July 1, 2016
Last Updated Month/Year
January 5, 2023
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