Using narrative reports to support a digital library

E A Mendonça1, J J Cimino, S B Johnson

  • 1Department of Medical Informatics, Columbia University, New York, NY, USA.

Related Concept Videos

Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Types of Reports I: Hand-off Report01:25

Types of Reports I: Hand-off Report

A hand-off report, also known as a change-of-shift report, is a crucial nursing process that ensures the smooth transition of patient care responsibilities between nursing staff.
Following are the key components and categories of hand-off reports:
Purpose and Process:
Types of Reports III: Telephone and Verbal Reports01:26

Types of Reports III: Telephone and Verbal Reports

Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
Social Foundations of Self IV: Self in Digital Communication01:30

Social Foundations of Self IV: Self in Digital Communication

Since the early 2000s, computer-mediated communication (CMC) has grown rapidly, playing a crucial role in self-development. A key distinction between CMC and real-life interactions is the lack of a physically present partner. This absence makes non-verbal cues such as facial expressions, body language, and paralinguistic signals unavailable in CMC platforms like email, instant messaging, or social media. The lack of these cues can create ambiguity and complicate how feedback is interpreted.The...