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Sample view of an electronic health record in action. Electronic medical records are a more efficient way of storing medical information, yet there are many negative aspects of this type of filing system as well. Hospitals are willing to adopt this type of filing system only if they are able to ensure that the private information of their ...
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
Names; All geographical identifiers smaller than a state, except for the initial three digits of a zip code if, according to the current publicly available data from the U.S. Bureau of the Census: the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; the initial three digits of a zip code for all such geographic units ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
The General Practice Data for Planning and Research system was set up by the British National Health Service as a replacement for the General Practice Extraction Service as a means of transmitting data intended for use beyond that of providing individual health care. This might include healthcare planning, or research.
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 ...
Client confidentiality is the principle that an institution or individual should not reveal information about their clients to a third party without the consent of the client or a clear legal reason. This concept, sometimes referred to as social systems of confidentiality , is outlined in numerous laws throughout many countries.
For example, under the US Economic Espionage Act of 1996, it is a federal crime in the United States to misappropriate trade secrets with the knowledge that it will benefit a foreign power, or will injure the owner of the trade secret. [19] More commonly, breach of commercial confidentiality falls under civil law, such as in the United Kingdom ...