Communication
Facilitates communication serving as a legal document and justifies financial billing and reimbursement of care.
What is the purpose of healthcare records?
Serves to facilitate communication, legal record of care, justifies financial billing and reimbursement.
What is the healthcare record?
Promoted meaningful use of health information technology to improve quality, safety and efficiency of health care.
Who is HITECH?
Organized by body system and navigate using the computer mouse using tabs and rows.
What is flow sheets?
Information system and other technologies use to record, monitor, and deliver patient care, and to perform managerial and organizational functions.
What is Health information technology (HIT)?
A communication strategy that produces a written account of patient data, clinical decisions, interventions and patient responses.
What is documentation?
Limits liability follows organization standards, and goal-directed nursing care, mistakes can result in malpractice.
What is legal documentation?
Individual lifetime computerized record
What is an electronic health record?
The format is traditional and records patient assessment, clinical decisions, and care provided - storyline format.
What is narrative documentation?
What is a nursing clinical information system?
Implementation of policies where hospitals are no longer reimbursing treatment that is hospital-acquired conditions "never events"
Who are the Centers for Medicare and Medicaid?
Classifications based on hospitalized patient's primary and secondary diagnoses for the basis of reimbursement.
What is Diagnosis -related groups?
Patient records within a system that provided continuous access allowing authorized providers access at any time. Lifetime patient record and measures cost and quality.
What is electronic medical record?
Normal assessment findings or activities are met unless otherwise documented.
What is charting by exception?
Integrates nursing science, computer science, and information science to manage and communicate data.
What is nursing informatics?
Stage III and IV pressure injuries falls with injuries, catheter-associated urinary tract infections, and central line-associated bloodstream infections
What are preventable adverse events "nurse sensitive"?
Regulations from agencies requiring monitoring and evaluation of quality and appropriateness of patient care.
Who are the Joint Commission and Centers for Medicare and Medicaid Services?
Fundamental responsibility of all members of the health care team
What is the confidentiality of health records?
Factual, accurate, current, and appropriate use of abbreviations in documentation, organized, and complete.
What are the guidelines for quality documentations?
Computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication in a healthcare organization.
What is a healthcare information system?
Medical record communicates the type and frequency of patient care delivered
What is accountability?
Random numbers are used for labeling and categorizing forms and also can be used for statistical analysis.
What is re-identification?
The first federal legislation to provide protection for patient records, it governs all areas of patient information and management of information.
What is HIPAA?
Narrative note, PIE (nursing problem, intervention, evaluation), focus charting, SOAP (subjective, objective, assessment, and plan)
What are different formats in nursing documentation?
Shifting to electronic documentation to deliver safe and efficient care to implement evidence-based practices.
What is healthcare informatics?