Related Experiment Video
Updated: Jun 28, 2026
03:47
Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients
Published on: July 12, 2024
2008 HIMSS Survey results: best practices in implementing nursing/interdisciplinary documentation systems.
Susan K Newbold1, Kathleen C Kimmel, Randy O'Steen
1Vanderbilt School of Nursing, Nashville, TN, USA.
AMIA ... Annual Symposium Proceedings. AMIA Symposium
|November 13, 2008
Summary
Implementing computerized nursing documentation systems requires understanding varied deployment processes. This survey explored hospital practices to develop best practice guidelines for nursing informatics professionals and executives.
Area of Science:
- Nursing Informatics
- Health Information Management
- Healthcare Systems Engineering
Background:
- Healthcare organizations widely use computer systems for nursing documentation.
- Processes for deploying these systems are highly variable.
- There is a need for established best practice guidelines.
Purpose of the Study:
- To understand current practices in implementing computerized nursing and interdisciplinary documentation systems.
- To identify key processes involved in system deployment.
- To establish best practice guidelines for future implementations.
Main Methods:
- A survey was conducted in Spring 2007.
- Members of the Healthcare Information Management and Systems Society Nursing Informatics Working Group interviewed 15 hospitals.
- Information was gathered on leadership, clinical transformation, project management, implementation, evaluation, standards, and end-user adoption.
Main Results:
- The survey gathered data on diverse hospital practices for system implementation.
- Specific details on leadership activities, clinical transformation, project management, and implementation processes were collected.
- Information on evaluation metrics, standards used, and end-user adoption strategies was solicited.
Conclusions:
- Results provide insights into current practices for implementing computerized nursing documentation systems.
- The findings are valuable for nursing informatics professionals and executives planning system implementations.
- This study serves as a foundation for developing best practice guidelines.
Related Concept Videos
01:26Guidelines for Nursing Documentation II
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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.
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.
01:29Documentation 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
Long-Term Care Facilities
01:30Guidelines 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.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:28Formats 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...
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...
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
01:30Methods of Documentation VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...