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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.
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
They may work in a broad range of settings that span the continuum of healthcare including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. Health information managers may specialize in registry management, data management, and data quality among other areas.
It makes the process of nursing assessment visible through what is presented in the documentation content. [4] During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5]
The process for information exchange, in this case the transfer of lab results to the attending physician, depends on the structure for receiving and interpreting results. The structure could involve an electronic health record (EHR) that a laboratorian fills out with lab results for use by the physician to complete a diagnosis. To improve this ...
Laboratory quality control is designed to detect, reduce, and correct deficiencies in a laboratory's internal analytical process prior to the release of patient results, in order to improve the quality of the results reported by the laboratory.
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes. [67] This type of event monitoring has been implemented using the Louisiana Public health information exchange linking statewide public health with electronic medical records.