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Using clinical data for nursing research and management in health services

Liza Heslop1, Brendon Gardner, Donna Diers

  • 1Centre for Health Services Operations Management, Monash University, Melbourne, Australia.

Contemporary Nurse
|October 13, 2007
PubMed

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Nursing Clinical Information System01:27

Nursing Clinical Information System

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Critical attributes of NCIS include:
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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...
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Nursing Interventions II: Selecting and Classifying the Nursing Interventions

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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,...