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Related Concept Videos

Discharge Summary Forms01:31

Discharge Summary Forms

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
Methods of Documentation VII: EMR01:30

Methods 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,...
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:
Flow Sheet01:17

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
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 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:

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Related Experiment Videos

Experiences with the electronic nursing discharge summary.

Anne Kuusisto1, Paula Asikainen, Heli Lukka

  • 1Satakunta Hospital District, Pori, Finland. anne.kuusisto@satshp.fi

Studies in Health Technology and Informatics
|July 14, 2009
PubMed
Summary

Nursing staff reported positive experiences with the Electronic Nursing Discharge Summary (ENDS), finding it enables effective communication. Careful implementation is key for successful adoption of this documentation tool.

Related Experiment Videos

Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Healthcare Management

Background:

  • The Salpa project aimed to implement a regional information system in Finland.
  • Electronic Nursing Discharge Summary (ENDS) is a crucial tool for patient transfer and continuity of care.

Purpose of the Study:

  • To describe nursing staff experiences with the Electronic Nursing Discharge Summary (ENDS).
  • To evaluate the usability and satisfaction of ENDS among healthcare professionals.

Main Methods:

  • Qualitative study involving phone interviews with 22 nurses (processing and receiving ENDS).
  • Content analysis was used to analyze interview data.
  • Study conducted in 2006 as part of the Satakunta Hospital District's Salpa project.

Main Results:

  • Nursing staff reported mainly positive experiences with the ENDS.
  • ENDS facilitates real-time, safe, and timely communication when used carefully.
  • Documentation process and system acceptance are more critical than IT skills for successful implementation.

Conclusions:

  • The ENDS serves as a valuable guiding tool for nurses' daily documentation.
  • Careful consideration of the system's structure and acknowledging documentation time are necessary.
  • Successful adoption hinges on the acceptance of the nursing documentation process.