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Guideline Implementation: Patient Information Management.

Jennifer L Fencl

    AORN Journal
    |November 29, 2016
    PubMed
    Summary

    The updated AORN guideline offers perioperative nurses best practices for managing patient information in electronic health records to improve care quality and safety. It emphasizes data capture, standardized terminology, and data security.

    Keywords:
    clinical documentationdata managementpatient informationperioperative ordersstructured data

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    Area of Science:

    • Nursing Informatics
    • Healthcare Management

    Background:

    • Clinical documentation is vital for patient care.
    • Electronic health records (EHRs) enable data aggregation for improved healthcare.
    • The Association of periOperative Registered Nurses (AORN) provides guidelines for patient information management.

    Purpose of the Study:

    • To highlight key aspects of the updated AORN "Guideline for patient information management."
    • To guide perioperative personnel in documenting and managing patient data effectively.

    Main Methods:

    • Focuses on data capture supporting clinical workflows.
    • Incorporates professional guidelines, standards, and regulatory reporting.
    • Emphasizes standardized clinical terminologies for data consistency.

    Main Results:

    • Addresses data aggregation for research and analytics.
    • Includes considerations for patient care orders.
    • Details safeguards for patient security and confidentiality.

    Conclusions:

    • Perioperative RNs must review the guideline for policy and procedure updates.
    • Effective patient information management enhances care safety, quality, and efficacy.
    • Adherence to the guideline supports evidence-based practice and regulatory compliance.