Nurses' perceptions of feed-back from the electronic patient record for the quality on pressure ulcer care

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:

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:

The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.
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Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning, patient...

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,...

Establishing a secure, collaborative nurse-patient relationship is crucial for delivering high-quality care. This relationship, founded on trust, respect, and honesty, enhances the patient's comfort and willingness to share vital health information. For example, a nurse who listens actively and without judgment provides clear information about health conditions and treatment options and respects patient decisions, which builds a trusting relationship.
Communication between nurses and patients...