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Klinik dokümantasyon iyileştirme programı konusunda bir rehber

A primer on Clinical Documentation Improvement Program

Journal Name:

  • Sağlık Akademisyenleri Dergisi

Publication Year:

  • 2016
DOI: 
10.5455/sad.13-1467646960

Key Words:

Keywords (Original Language):

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Abstract (2. Language): 
The 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.
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Abstract (Original Language): 
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 faz la verim kazandırmaktır.
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  • Turkish

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