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Point of care
Clinical point of care is when clinicians deliver healthcare products and services to patients at the time of care.〔Information at the Point of Care: Answering Clinical Questions. Ebell, Mark. "American Board of Family Practice". Michigan State University, 1999, 12(3), 225-235.〕
==Clinical documentation==
Documentation performed at the time of clinical point of care can be conducted using paper or electronic formats. This process aims to capture medical information pertaining to patient's healthcare needs. The patient's health record is a legal document that contains details regarding patient’s care and progress.〔Documentation Guidelines for Registered Nurses. College and Association of Registered Nurses of Alberta. 2006. http://www.nurses.ab.ca/carnaadmin/uploads/documentation%20for%20registered%20nurses.pdf.〕 The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient’s healthcare needs, goals, diagnosis and the type of care they have received from the healthcare providers.〔Documentation, Revised 2008. College of Nurses of Ontario. 2008. http://www.cno.org/Global/docs/prac/41001_documentation.pdf.〕
Such documentations provide evidence regarding safe, effective and ethical care and insinuates accountability for healthcare institutions and professionals. Furthermore, accurate documents provide a rigorous foundation for conducting appropriate quality of care analysis that can facilitate better health outcomes for patients.〔Keenan, G.M, Yakel, E., Tschannen, D., & Mandeville, M. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (version ). Rockville, MD: Agency for Healthcare Research and Quality.〕 Thus, regardless of the format used to capture the clinical point of care information, these documents are imperative in providing safe healthcare. Also, it is important to note that electronic formats of clinical point of care documentation are not intended to replace existing clinical process but to enhance the current clinical point of care documentation process.
抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』
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