What is the meaning of computerized documentation?
Background. Computerized clinical documentation systems (CDS) provide for the documentation of patient care using computers. For example, the CDS records the vital signs directly from the cardio-respiratory monitors, while other documentation, such as nursing assessments are entered by the clinician.
What is falsifying documentation nursing?
Falsification of nursing documentation; unprofessional conduct likely to deceive, defraud or harm the public; and not meeting standards of nursing practice are examples of grounds upon which the board could allege against the nurse managers.
What is computerized charting?
the keeping of a clinical record of the important facts about a patient and the progress of his or her illness.
What is kardex in nursing?
Quick Reference. (kar-deks) originally, the proprietary name for a filing system for nursing records and orders that was held centrally on the ward and contained all the nursing details and observations of patients that had been acquired during their stay in hospital.
What is the purpose of nursing Kardex?
The defining elements of the Kardex include that it was a formally sanctioned paper-based information system for nurses working in a hospital unit to support situation awareness and activity planning during a patient’s stay on the unit.
What is an EDM system?
An Electronic Document Management System (EDMS) is a collection of technologies that work together to provide a comprehensive solution for managing the creation, capture, indexing, storage, retrieval, and disposition of records and information assets of the organization.
How nurses use electronic health records?
Table 2
| Routine User | ||
|---|---|---|
| Electronic medical information about patients, including problem list, key patient demographics | 16% | 34% |
| Electronic ordering of tests, procedures, or drugs | 30% | 25% |
| Electronic clinical and patient notes | 18% | 40% |
| Electronic access to test results | 14% | 15% |
What happens if a nurse falsified documentation?
The ramifications of falsifying records may be a nursing liability, encumbered license, or loss of your license. Another consequence is, your veracity as a nurse will be severely compromised.
What is considered false documentation?
False documentation is the process of creating documents which record fictitious events. The documents can then be used to “prove” that the fictional events happened.
Can a Tier 2 document be clearly defined?
However, Tier 2 documents are not clearly defined and as a result, the QMS is somewhat fragmented within the organization. I am looking to move the QMS from mere certification toward an organization with measured process effectiveness and continual improvement at its core.
What are the three tiers of ISO9001 documentation?
With my last employer, I’ve developed and maintained the Quality Management System through the 1994, 2000, and 2008 versions of the ISO9001 standard using the 3 tier documentation approach – the QA Manual, Tier 2 QMS documents, and work instructions. My current company employs 500 people with a presence in the US, Canada, Europe.
What are the general guidelines for nursing documentation?
In addition, general guidelines to follow include: Always assess the patient at the time of discharge or transfer. It’s vital to know the status of a patient before he leaves or enters your care. Always use a chronologic documentation format, providing separate entries for each narrative item.