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A key communication strategy that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record.
Documentation
A combination of hardware and software that protects private network resources.
Firewall
A document that is composed whenever an incident occurs.
Incident Report (Occurrence Report)
Systematically developed statements to assist practitioner decisions about appropriate health care for specific circumstances.
Clinical Practice Guidelines (CPG's)
Incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery.
Nursing Clinical Information System
Where the documentation of a patient's medical information is kept.
Health record
Meaningful Use
The system used to determine the hours of care and the number of staff required for a given group of patients every shift or every 24 hours.
Acuity rating system
An organized system for delivering health care to an individual patient or group of patients across an episode of illness and or/continuum of care; includes assessment and development of a plan of care, coordination of all services, referral, and follow-up; usually assigned to one professional.
Case Management
The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice.
Nursing Informatics
Classifications based on hospitalized patient's primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care.
Diagnosis-related groups (DRGs)
Any information about health status, provision of health care, or payment for health care that is created or collected by a covered entity, and can be linked to a specific individual.
Protected Health Information (PHI)
Interprofessional care plans that identify patient problems, key interventions, and expected outcomes with an established time frame.
Critical Pathways
Unexpected outcomes, unmet goals, and interventions not specified within a critical pathway.
Variances
A system that allows health care providers to directly enter standardized, legible, and complete orders for patient care into a medical record from any computer in the HIS.
Computerized Provider Order Entry
An electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery system.
Electronic Health Record
The format traditionally used by nurses and healthcare providers to record patient assessment, clinical decisions, and provided; consists of a story-like format to document information.
Narrative Documentation
The use of information systems and other information technology to record, monitor, and deliver patient care, and to perform managerial and organizational functions in health care.
Health Information Technology (HIT)
Computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in the health care organization.
Health Care Information System
A computerized program that aids and supports clinical decision making.
Clinical Decision Support System
Part of the electronic health record that contains patient data gathered in a healthcare setting at a specific time and place.
Electronic Medical Record
Charting methodology in which data are entered only when there is an exception from that which is normal or expected; reduces time spent documenting in charting. It is a shorthand method for documenting normal findings and routine care.
Charting by exception (CBE)
Written care plans used for groups of patients who have similar health care problems.
Standardized Care Plans
A large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care.
Clinical Information System (CIS)
Applications of computer and information science in all basic and applied biomedical sciences to facilitate the acquisition, processing, interpretation, optimally used, and communication of health-related data
Health Care informatics