1. Patient Health Care Records ...................................................................................................... 390 Assessment, nursing interventions
2. Documentation and Nursing Workflow P ................................................................................ 391
3. Structured Vocabularies ............................................................................................................. 393 Perioperative Nursing Data Set, standardization
4. Comprehensive Representation of Care P ............................................................................... 394 Regulatory requirements, professional guidelines and standards, accreditation organization requirements, charting by exception
5. Security and Confidentiality P .................................................................................................. 400 HIPAA, organizational information-sharing policies, authentication process, record retention
6. Modifying Existing Records ......................................................................................................... 402 7. Education ...................................................................................................................................... 403 8. Policies and Procedures .............................................................................................................. 404
P indicates a recommendation or evidence relevant to pediatric care.
MEDICAL ABBREVIATIONS & ACRONYMS
ARRA – American Recovery and Reinvestment Act CDI – Clinical documentation improvement CMS – Centers for Medicare & Medicaid Services EHR – Electronic health record EMR – Electronic medical record FTP – File transfer protocol HIPAA – Health Insurance Portability and Accountability Act
HITECH – Health Information Technology for Economic and Clinical Health
ONC – Office of the National Coordinator for Health Information Technology
PNDS – Perioperative Nursing Data Set RN – Registered nurse SNOMED-CT – Systematized Nomenclature of Medicine—Clinical Terms
