Klinik dokümantasyon iyileştirme programı konusunda bir rehber

Yıl 2016, Cilt: 3 Sayı: 2, 74 - 76, 01.04.2016

Pavani Priyadarsini

Öz

Klinik Belgelemenin alanı hekimlerin belgelerinden daha fazlasını kapsamak amacıyla geliştirildi.Şu an Klinik Belgeleme
laboratuvar raporlarını,teknisyen belgelerini , bakım belgelerini vb.içeriyor.Ayrıca Klinik Belgeleme , hastaya sunulan
bakımla diğer bakım ekibinin üyeleri arasındaki iletişimi kurar.Şu aralar tedarikçi kurumlar,teknoloji sağlayıcılar,kamusal
düzenleyiciler ve muhataplar gibi diğer paydaşlar doğrudan hasta bakımının haricinde Klinik Belgeleme sürecindeki
ek gereksinimlerdeki yerlerini aldı.Klinik Belgeleme Gelişim Programının amacı Klinik Belgeleme kalitesini artırmak
ve bu belgelemeye hasta bakımı gelişimi konusunda çok daha fazla verim kazandırmaktır.

Anahtar Kelimeler

Belge, Hasta bakımı, Sağlık bilgi yönetimi, Klinik kodlama

A primer on Clinical Documentation Improvement Program.

Öz

AbstractThe domain of Clinical Documentation (CD) has grown to encompass more than just physician notes. Now CD includes Laboratory reports, Operative notes, Nursing notes, etc.CD is also to communicate the care given to the patient to other members of the care team. Now other stakeholders like provider institutions, technology vendors, government regulators and payers have placed additional requirements on the CD process for purposes other than direct care of the patient. The aim of CD improvement program is to improve the quality of CD and to better use this documentation to improve patient care.

Anahtar Kelimeler

Documentation, Patient care, Health Information Management, clinical coding

Kaynakça

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