Information Management

• Published in: AORN journal 2023-11, Vol.118 (5), p.332-337
• Main Author: Kyle, Erin
• Format: Article
• Language: English
• Subjects: American Recovery & Reinvestment Act 2009-US; Anesthesia; Clinical decision making; Collaboration; Documentation; Electronic health records; Information management; Information technology; Informed consent; Interdisciplinary aspects; Interoperability; Multidisciplinary teams; Nurses; Nursing; Personnel selection; Reimbursement; Surgeons
• ISSN: 0001-2092; 1878-0369
• DOI: 10.1002/aorn.14024

1.2 © https://aorn.us/nov23-b2b The primary purpose of clinical documentation in health care settings is to provide a structure for communication among caregivers to facilitate optimal care coordination throughout the continuum and promote the best patient outcomes.1 Information management involves health record design, technology system evaluation, and patient care documentation.2 Perioperative nurses and leaders can use data entered into information management systems to measure metrics associated with care delivery. Effective design and use of perioperative information management systems can provide a foundation for optimal communication among all members of the perioperative team.12 Perioperative RNs review the electronic health record (EHR) or paper documents to verify completeness and plan intraoperative patient care.2 They also document nursing interventions and patient assessments relative to the perioperative plan of care. Health Information Technology and Standardized Vocabularies Facility leaders should implement health information technology (HIT) systems for documentation in perioperative areas.2 According to the American Recovery and Reinvestment Act of 2009, HIT includes the hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information.3 The facility's HIT systems must either be certified or meet governmental certification criteria.4 Facility leaders should implement HIT systems to standardize EHR documentation for continuity of patient care and improved interoperability (ie, exchange of information across boundaries).2 Structured clinical vocabularies in HIT systems can enhance interoperability among electronic systems and may contribute to improved documentation, knowledge generation, and use of clinical guidelines.5 Vocabularies can be incorporated into clinical decision support-interactive computer-based programs in an EHR that provide advice, reminders, or data interpretation to facilitate decision making at the point of care.2 Integrating a standardized vocabulary into the organization's EHR can help personnel leverage the data entered during patient care. The perioperative record should incorporate standardized frameworks and terminologies to promote interoperability of health care data and support a ce