Introduction

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.