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The PROMIS initiative develops and evaluates standard measures for key patient-reported health indicators and symptoms. [5] Patient-reported measures such as pain, fatigue, emotional distress, and physical functioning complement clinical measures (e.g., x-rays and lab tests) by providing healthcare providers with information about what patients ...
Quality tools include: [1] Medical guidelines, including checklists [2] (items rated as yes/no/not applicable); Templates [3] for goal setting or structured communication (a more open format than checklists, templates provide the opportunity to add free text responses with items as prompts)
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems.The questionnaire takes less than one minute to administer, [1] and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism.
To provide the safe and effective delivery of medical care, virtually all clinical staff use a number of front-line health informatics tools in their day-to-day operations. The need for standardization and refined development of these tools is underscored by the HITECH Act and other efforts to develop electronic medical records .
The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
Continuity of Care Record (CCR) [1] is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.