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Guideline Implementation: Patient Information Management
Author(s) -
Fencl Jennifer L.
Publication year - 2016
Publication title -
aorn journal
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.222
H-Index - 43
eISSN - 1878-0369
pISSN - 0001-2092
DOI - 10.1016/j.aorn.2016.09.020
Subject(s) - documentation , guideline , workflow , confidentiality , health care , medicine , patient safety , quality management , medical emergency , nursing , computer science , operations management , management system , computer security , pathology , database , economics , programming language , economic growth
Clinical documentation captured in a patient's record provides health care personnel with information that can be used to guide patient care. Data collected in electronic health records can be accessed and aggregated across the health care delivery system to enhance the safety, quality, and efficacy of care. The updated AORN “Guideline for patient information management” provides guidance to perioperative personnel on documenting and managing patient information. This article focuses on key points of the guideline, which address data capture that supports the clinical workflow, incorporation of professional guidelines and standards as well as regulatory and mandatory reporting elements, use of standardized clinical terminologies, data aggregation for use in research and analytics, considerations for patient care orders, and safeguards for the patient's security and confidentiality. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.