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Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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Methods of Documentation III: PIE01:21

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Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
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Methods of Documentation VI: Case Management Model01:15

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Related Experiment Video

Updated: Jul 11, 2026

Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments
08:36

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First wave PMS pilots: a critical analysis of documentation.

V Allgar1, B Leese, P Heywood

  • 1Centre for Research in Primary Care, University of Leeds, UK.

Journal of Management in Medicine
|January 5, 2002
PubMed
Summary

Pilot project contracts and evaluation reports varied significantly. Clearer objectives, measurable milestones, and defined evaluation strategies are essential for effective project management and success measurement in future pilots.

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Area of Science:

  • Health Services Research
  • Program Evaluation

Background:

  • Analysis of 14 first-wave Primary Medical Services (PMS) pilots in Northern and Yorkshire.
  • Examination of contracts and interim local evaluation reports.

Purpose of the Study:

  • To assess the quality and clarity of contracts and evaluation reports for PMS pilots.
  • To identify areas for improvement in pilot project management and evaluation.

Main Methods:

  • Documentary analysis of contracts and evaluation reports.
  • Qualitative assessment of scope, objectives, milestones, and evaluation criteria.

Main Results:

  • Significant variation in contract and report size and scope.
  • Broad or vague objectives and lack of clear milestones in most contracts.
  • Difficulty in establishing success criteria due to unclear objectives.
  • Variable quality of local evaluation reports.

Conclusions:

  • Contracts require development plans with specific objectives, timescales, and measurable milestones.
  • Agreed-upon weighting for partial success is necessary.
  • Enhanced clarity in contracts and evaluation frameworks is crucial for future pilot programs.