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  2. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]

  3. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements.

  4. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    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.

  5. Nursing Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Nursing_Minimum_Data_Set

    The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...

  6. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.

  7. Computerized physician order entry - Wikipedia

    en.wikipedia.org/wiki/Computerized_physician...

    Access is secure, and a permanent record is created, with electronic signature. Portability The system accepts and manages orders for all departments at the point-of-care, from any location in the health system (physician's office, hospital or home) through a variety of devices, including wireless PCs and tablet computers. Management

  8. Nursing home care in the United States - Wikipedia

    en.wikipedia.org/wiki/Nursing_home_care_in_the...

    Board and care homes (residential care homes) are special facilities designed to provide those who require assisted living services both living quarters and proper care. These facilities can either be located in a small residential home or a large facility. A large majority of board and care homes are designed to room less than 6 people.

  9. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    An example of a nursing care plan in an Australian residential aged care home. Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing ...