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Capture patient care data using a standardized coded nursing terminology. Code electronic clinical encounters: diagnoses, interventions, and outcomes. Track nurses' contribution to patient care and care outcomes. Provide standardized concepts (data/elements) for clinical pathways and decision support.
The International Labour Organization's International Standard Classification of Occupations further notes: "Occupations included in this category require knowledge of medical terminology, legal aspects of health information, health data standards, and computer- or paper-based data management as obtained through formal education and/or ...
Lawrence Leonard Weed (December 26, 1923 – June 3, 2017) [1] was an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records.
Health information technology (HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, health data, and knowledge for communication and decision making". [8]
Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...
Some of the problems tackled by CRI are: creation of data warehouses of health care data that can be used for research, support of data collection in clinical trials by the use of electronic data capture systems, streamlining ethical approvals and renewals (in US the responsible entity is the local institutional review board), maintenance of ...
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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.