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Documentation of Nursing Diagnosis

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...

Role of Communication in the Nursing Process I: Assessment and Diagnosis

Role of Communication in the Nursing Process I: Assessment and Diagnosis

The nursing process uses scientific reasoning, problem-solving, and critical thinking to guide nurses in providing patients with appropriate care. This process is a systematic approach to recognize, avoid, and treat current or potential health issues while promoting the patient's well-being.
The nursing process considers the patient's emotional and physical well-being. The process can be repeated or stopped at any point if judged essential. Assessment is the first step in the nursing process.

Nursing Clinical Information System

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:

Nursing Diagnosis

Nursing Diagnosis

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
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Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis

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Patient-centered Care

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Related Experiment Video

Updated: Jun 15, 2026

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

Published on: May 10, 2022

Nurses' responses to differing amounts and information content in a diagnostic computer-based decision support

InSook Cho¹, Nancy Staggers, Ihnsook Park

¹Department of Nursing, Inha University, Incheon, South Korea. insook.cho@inha.ac.kr

Computers, Informatics, Nursing : CIN

|February 26, 2010

Summary

This summary is machine-generated.

Designing effective nursing decision support systems requires considering the varying information needs of expert and novice nurses. Tailoring the amount of displayed information, not just its content level, is crucial for optimal system performance.

Related Experiment Videos

Last Updated: Jun 15, 2026

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

Published on: May 10, 2022

Area of Science:

Nursing Informatics
Clinical Decision Support Systems
Human-Computer Interaction

Background:

Nurses frequently make critical decisions with limited diagnostic data under time constraints.
Computerized decision support systems offer potential for precise, context-aware utilization of nursing diagnostic information.

Purpose of the Study:

To determine optimal information amounts and content levels for designing diagnostic nursing decision support systems.
To investigate the impact of probability data and the number of displayed nursing problems on expert and novice nurses.

Main Methods:

A counterbalanced, repeated-measures, factorial design was employed.
Two patient scenarios (pneumonia with diabetes complications, bone fracture with diabetes) were utilized.
A prototype diagnostic nursing decision support system presented information to 18 expert and novice nurses in Korea.

Main Results:

No significant differences were found in preferred information content levels based on nursing expertise.
A significant difference emerged in the preferred amount of information displayed between novice and expert nurses.
Expertise level significantly influenced the preferred quantity of information presented by the decision support system.

Conclusions:

Future computer-based decision support systems must account for the distinct information requirements of both novice and expert nurses.
Tailoring the volume of displayed information is a key factor in optimizing nursing decision support tools.