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Related Concept Videos

Flow Sheet01:17

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
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.
For example, a patient with a chronic illness...
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

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:
Formats for Nursing Documentation01:28

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:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...

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Related Experiment Video

Updated: Jul 14, 2026

Design and Analysis for Fall Detection System Simplification
08:05

Design and Analysis for Fall Detection System Simplification

Published on: April 6, 2020

A flowchart system to improve fall data documentation in a long-term care institution: a pilot study.

Manuel Montero-Odasso1, Paula Levinson, Brian Gore

  • 1Division of Geriatric Medicine, University of Western Ontario, London, Ontario, Canada. mmontero@uwo.ca

Journal of the American Medical Directors Association
|June 16, 2007
PubMed
Summary

Implementing a flowchart system significantly improved fall data documentation in long-term care facilities. This enhanced data collection aids in identifying risk factors and developing effective fall prevention programs for older adults.

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Area of Science:

  • Gerontology
  • Healthcare Quality Improvement
  • Patient Safety

Background:

  • Falls are a major cause of morbidity and mortality in the elderly, particularly in long-term care (LTC) settings.
  • Current LTC practices often neglect comprehensive assessment of fall risk factors and episode characteristics, focusing instead on injury consequences.
  • There is a need for improved data collection and secondary prevention strategies for falls in LTC institutions.

Purpose of the Study:

  • To document current fall data documentation practices within a specific LTC center.
  • To evaluate the effectiveness of a newly implemented flowchart system in improving fall data documentation.
  • To assess if the flowchart system enhances the identification of fall risk factors and facilitates appropriate referrals.

Main Methods:

  • A flowchart system with a standardized form was developed to guide the documentation of fall characteristics, identify post-fall risk factors, and suggest referrals.
  • Educational sessions were conducted to train staff on the rationale and use of the flowchart system.
  • Audits of incident report data were performed before and two months after the system's implementation to compare documentation quality.

Main Results:

  • Audits included 107 incident reports, with an average participant age of 82.7 years; 53% had dementia.
  • Significant improvements were observed in documenting previous falls (95% vs. 35%) and the place of fall (89% vs. 32%) after system implementation.
  • The flowchart system facilitated the collection of previously unrecorded data, including polypharmacy, psychotropic medication use, and specific fall etiologies.

Conclusions:

  • The introduction of the flowchart system significantly enhanced the documentation of fall risk factors and episode characteristics in LTC.
  • Referrals to geriatricians for falls evaluation increased significantly following the implementation of the flowchart system.
  • This simple strategy, combining education and a flowchart system, improves fall data documentation and supports the development of falls prevention programs in nursing homes.