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Collect these data to assess nursing quality

    Healthcare Benchmarks and Quality Improvement
    |August 9, 2008
    PubMed

    Related Concept Videos

    Nursing Assessment01:29

    Nursing Assessment

    The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
    The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...
    Nursing Evaluation01:15

    Nursing Evaluation

    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.
    Section...
    Data Collection III01:05

    Data Collection III

    The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
    The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
    Data Collection I01:30

    Data Collection I

    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...
    Guidelines for Nursing Documentation I01:30

    Guidelines for Nursing Documentation I

    Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
    Factual:  
    The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
    Purpose of Health Records I01:11

    Purpose of Health Records I

    The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
    Here's a breakdown of how health records serve these purposes: