Documentation System Medical Informatics

Improving clinical documentation: introduction of …

https://bmjopenquality.bmj.com/content/10/1/e000918

Critically, documentation of patient’s name (49%–58%), patient identification (42%–51%), recording of clinician’s grade (51%–76%) and recording of most senior clinician (75%–37%) remained well below required standards of ≥90% at phased improvement …

eHealth and Clinical Documentation Systems - PubMed

https://pubmed.ncbi.nlm.nih.gov/32990673/

eHealth is the use of modern information and communication technology (ICT) for trans-institutional healthcare purposes. Important subtopics of eHealth are …

Clinical Documentation Integrity Education & Training

https://www.ahima.org/education-events/education-by-topic/

Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, …

Nurse documentation and the electronic health record

https://www.myamericannurse.com/documentation-electronic-health-record/

Healthcare Informatics | HIMSS

https://www.himss.org/resources/healthcare-informatics

The American Nurses Association (ANA) identified nursing informatics as “a specialty that integrates nursing, science, computer science, and information …

Data Standards in Healthcare: Codes, Documents, and …

https://www.altexsoft.com/blog/data-standards-healthcare/

In the US, the privacy and security standards for medical information are outlined by the Health Insurance Portability and Accountability Act . Among other things, it formalizes the use of ICD-10-CM, CPT, HCPCS, CDT, and …

Documentation and Informatics | Nurse Key

https://nursekey.com/documentation-and-informatics/

There are several documentation systems for recording patient data. Regardless whether documentation is entered electronically or on paper, each health care agency selects a documentation system that …

The Implementation of Electronic Clinical Documentation …

https://cjni.net/journal/?p=2882

Electronic clinical documentation, also known as computerized documentation or computer-based documentation is an electronic information system used by nurses and other …

Health Information Management History: Past, Present

https://www.rasmussen.edu/degrees/health-sciences/blog/health-information-management-history/

Medical records in the information age Paper medical records were steadily maintained from the 1920s onward, but the advancing technology of the ‘60s and ‘70s introduced the beginnings of a new system. The …

Clinical documentation | How to document medical …

https://onthewards.org/how-to-document-well/

Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into a cost for the hospital system. Thorough …