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Data Collection II

Data Collection II

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,...

Data Collection I

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...

Nursing Assessment

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...

Data Collection III

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 Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Data Collection by Observations

Data Collection by Observations

Data collection refers to a systematic way of obtaining, observing, measuring, and analyzing accurate information. Observational studies are one of the most widely used methods of data collection. It involves collecting data by observing the behavior and physical characteristics of a sample without making any modifications to the sample.
An astronomer viewing the motion and brightness of stars in the sky and recording the data is an example of observational data collection. A botanist recording...

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A Novel Method for Involving Women of Color at High Risk for Preterm Birth in Research Priority Setting

A Novel Method for Involving Women of Color at High Risk for Preterm Birth in Research Priority Setting

Published on: January 12, 2018

Midwifery data collection: options and opportunities.

Deborah S Walker¹, Joan M Visger, Amy Levi

¹Wayne State University, College of Nursing and School of Medicine, OB/GYN, 5557 Cass Ave., Rm. 248, Detroit, MI 48202, USA. dswalker@wayne.edu

Journal of Midwifery & Women'S Health

|September 2, 2008

Summary

Midwives recognize the value of clinical data for maternal and infant health. However, many use self-designed tools and are unaware of standardized options, hindering consistent data collection.

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Area of Science:

Midwifery
Clinical Data Collection
Health Outcomes Research

Background:

Midwives acknowledge the importance of clinical data for improving maternal and infant care.
Standardized data collection tools are available for individual midwives.
A significant portion of midwives use self-designed tools and are unaware of existing standardized datasets.

Purpose of the Study:

To review available clinical data collection tools for midwives.
To discuss the application and future directions of midwifery data collection.
To highlight the need for standardized data collection and a common database in midwifery.

Main Methods:

Survey of American College of Nurse-Midwives (ACNM) members on clinical data collection practices.
Review of existing midwifery clinical data collection instruments.
Discussion of the necessity for standardized data aggregation in midwifery.

Main Results:

51% of surveyed midwives reported using self-designed data collection tools.
Over one-third of respondents were unaware of the ACNM Nurse-Midwifery Clinical Data Sets (NMCDS).
The midwifery profession lacks a unified practice database for comprehensive data aggregation.

Conclusions:

There is a critical need for midwives to adopt uniform and standardized data collection methods.
Professional midwifery organizations should collaborate to develop a common electronic database.
Standardized data collection is essential for supporting midwifery practice, legislation, and policy at all levels.