Opportunities and obstacles in electronic data collection in nursing

Vesna Prijatelj1

  • 1University Medical Centre, Ljubljana, Slovenia. vesna.prijatelj@mf.uni-lj.si

Summary

Electronic data collection in nursing offers benefits but requires data standards and government support. Slovenia is outlined for achieving an electronic nursing record through strategic steps.

Related Concept Videos

Data Collection I01:30

Data Collection I

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of data...
Data Collection II01:29

Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
Data Collection III01:05

Data Collection III

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Nursing Assessment01:29

Nursing Assessment

The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...