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Clinical Nursing Skills

Introduction

Clinical Nursing SkillsIntroduction
A color photograph of a nurse and patient sitting at a kitchen table, both wearing masks. The nurse is using a tablet while the patient looks on.
Figure 4.1 A comprehensive assessment reveals critical information about a patient. Data collection, documentation, and the use of informatics in nursing are the foundation for obtaining an accurate health history. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Chapter Outline

4.1 Foundations for a Complete Electronic Health Record: Accurate Health History
4.2 Data Collection and Documentation
4.3 Informatics

According to the U.S. Department of Health and Human Services, health records are used for a variety of both administrative and clinical tasks to improve patients’ quality of care (2020). To avoid errors and inaccuracies in the diagnosis and treatment of a patient, it is imperative an accurate health history be obtained. While the health history is primarily used to better serve an individual patient, the information or data collected can have many other functions. Some of these functions include defining the medical facilities’ services, guiding future facility growth, and establishing trends in current practice. This chapter discusses the processes involved in obtaining a complete health history, data collection and documentation involved in a health history, and informatics.

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© Jun 25, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.