Related Concept Videos
01:11Guidelines for Writing Outcome
When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
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.
01:26Guidelines 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.
01:26Methods of Documentation IV: Focus Charting
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
It typically involves three columns for recording information:
01:23Methods of Documentation V: CBE
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
01:06Legal Guidelines for Documentation
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
You might also read
Related Articles
Articles linked to this work by shared authors, journal, and citation graph.
Sort by
Same author
Wolfrum Method: An Innovative Approach To the Y-Shoulder Examination.
Radiologic technology·2023
Same journal
An Intentional and Ethical Integration of AI in Medical Imaging.
Radiologic technology·2026
Same journal
Benefits of Integrating AI Into Computer-Aided Detection Systems.
Radiologic technology·2026
Same journal
Using Artificial Intelligence to Enhance Analysis of Chest Computed Tomography.
Radiologic technology·2026
Same journal
A Practice-Aligned Approach to Integrating AI in Radiation Sciences Education.
Radiologic technology·2026
Same journal
Site Visitors: The Unsung Heroes of the Accreditation Process.
Radiologic technology·2026
Related Experiment Video
Updated: Jun 26, 2026
10:07
Using Learning Outcome Measures to assess Doctoral Nursing Education
Published on: June 21, 2010
Faculty guide to rubrics
Geraldine Burghart1, Regina C Panettieri
1Radiologic Technology Program, Bronx Community College in New York, USA.
Radiologic Technology
|January 21, 2009
Summary
No abstract available in PubMed .
