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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.
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.
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]
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
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]
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 ...
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 ...
In 1953, care planning was not believed to be within the nursing scope of practice. [5] In the 1970s, care planning was activity based. [5] Patients were listed according to the procedures they were having done, which determined their plan of care. [5] Care provided was passed on by word of mouth, dressing books, and work lists. [5]