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Related Concept Videos

Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis01:24

Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis

The nursing process provides a clinical decision-making framework for patients and families to establish and implement a personalized care plan. Since part of the nurse's duties is to teach patients, the steps of the nursing process are the most effective way to approach instruction. The nursing process and the teaching-learning process are inextricably linked.
It is critical to determine the patient's learning needs during the assessment. Determination of learning needs compounds data from the...
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.
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...

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Related Experiment Video

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Computerized Adaptive Testing System of Functional Assessment of Stroke
05:21

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Testing a bedside personal computer Clinical Care Classification System for nursing students using Microsoft Access.

Veronica D Feeg1, Virginia K Saba, Alan N Feeg

  • 1Division of Nursing, Molloy College, Rockville Centre, NY 11571, USA. vfeeg@molloy.edu

Computers, Informatics, Nursing : CIN
|December 3, 2008
PubMed
Summary
This summary is machine-generated.

This study shows a new electronic charting system improves nursing care plan completeness. Students found the data-based system more positive for learning electronic charting.

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Area of Science:

  • Nursing Informatics
  • Health Information Technology
  • Educational Technology

Background:

  • Traditional charting methods can be time-consuming and may not fully capture patient care details.
  • There is a need for cost-effective, accessible tools to train nursing students in electronic charting.
  • The Sabacare Clinical Care Classification System offers a framework for standardized nursing documentation.

Purpose of the Study:

  • To evaluate the effectiveness of a personal computer-based Sabacare Clinical Care Classification System for teaching electronic charting to nursing students.
  • To compare student performance in charting patient care plans using a data-based system versus a text-based system.
  • To assess student perceptions regarding the usability and impact of the data-based charting system.

Main Methods:

  • A randomized trial was conducted comparing a data-based electronic charting system with a text-based system.
  • Nursing students used the systems to chart patient care plans in a laboratory setting.
  • Data collected included the completeness of care plans and student feedback on system usability.

Main Results:

  • Student care plans were significantly more complete when using the data-based system compared to the text-based system.
  • Students reported more positive experiences with the data-based system, although efficiency gains were not statistically significant.
  • The data-based system effectively captured standardized patient care information.

Conclusions:

  • The personal computer-based Sabacare system is effective in improving the completeness of nursing student care plans.
  • This application provides an affordable and practical method for teaching electronic charting and standardized documentation.
  • The system facilitates the integration of nursing care data with broader electronic health record systems.