Making the procedure manual come alive: A prototype relational database and dynamic website model for the management

Jane Peace1, Patricia Flatley Brennan

  • 1School of Nursing, University of Wisconsin-Madison, USA.

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Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
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Critical attributes of NCIS include:
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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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.
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Methods of Documentation II: POMR

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Formats for Nursing Documentation

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Nursing Assessment Form:
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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.
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