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.

Recommendation Grading




Patient Information Management

Authoring Organization

Publication Month/Year

July 1, 2016

Last Updated Month/Year

January 5, 2023

Document Type


External Publication Status


Country of Publication


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



Diseases/Conditions (MeSH)

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


hit, healthcare information, information management