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Budgeting nursing workload for required minimum data set assessments

Linda Adams-Wendling1, Jean DeDonder, Sarah Tidwell

  • 1Emporia State University, Newman Division of Nursing, Emporia, KS 66801, USA. ladamswe@emporia.edu

Journal of Nursing Management
|April 26, 2007
PubMed
Abstract

Related Concept Videos

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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:
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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,...