Related Experiment Videos
A nursing-specific model of EPR documentation: organizational and professional requirements
Gunn von Krogh1, Dagfinn Nåden
1Oslo University College, The Faculty of Nursing, Oslo, Norway. gunnvon.krogh@su.hio.no
Purpose:
To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR) functions the model is designed to address.
Methods:
The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year.
Results:
The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification.
Conclusions:
The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare.
Clinical Relevance:
The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.
Related Concept Videos
01:30Methods of Documentation VII: EMR
01:06Legal Guidelines for Documentation
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:28Formats for Nursing Documentation
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...