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Related Concept Videos

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...
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...
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...
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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 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...

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Nursing minimum data set: A literature review.

Reis Elisa1, Marin Heimar

  • 1Nursing of Interdisciplinary Care. elisa_reis@einstein.br

Studies in Health Technology and Informatics
|November 15, 2006
PubMed
Summary

Standardized nursing data sets, like the Nursing Minimum Data Set, are crucial for information technology systems. Their adoption facilitates research, trend analysis, and improved patient care, especially for the elderly and chronic disease patients.

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Area of Science:

  • Nursing Informatics
  • Health Information Management

Background:

  • Information technology systems are vital for accessing essential nursing information.
  • Standardized language is fundamental to accurately represent nursing data.
  • The Nursing Minimum Data Set and Nursing Management Minimum Data are key for data description, registration, and retrieval.

Purpose of the Study:

  • To conduct a literature review on the utilization of nursing minimum data sets for research.
  • To identify trends in nursing practice and data set application.
  • To assess the relevance of these data sets in contemporary healthcare.

Main Methods:

  • A literature review was performed.
  • Articles were selected from the Medical Literature Analysis and Retrieval System Online (MEDLARS) and regional library archives.
  • The search spanned from 1993 to 2005, including English and Portuguese publications.

Main Results:

  • Identified a need for dissemination and discussion of nursing data sets among Brazilian nurses.
  • Highlighted trends in care for the elderly and chronic disease patients.
  • Showcased the evaluation of nursing home care trends, cost justification, and care comparison.

Conclusions:

  • The increasing interest in nursing minimum data sets is driven by the need for timely and consistent information.
  • These data sets support research, trend analysis, and evidence-based nursing practice.
  • Effective use of data sets can improve the quality and efficiency of nursing care.