Related Concept Videos
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...
01:26Guidelines 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.
01:21Methods of Documentation III: PIE
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
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:
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.
01:30Methods 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,...
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Documenting an EBP project: guidelines for what to include and why.
Priscilla Sandford Worral1, Rona F Levin, Denise Côté Arsenault
1University Hospital, Upstate Medical University, Syracuse, NY, USA.
The Journal of the New York State Nurses' Association
|April 27, 2010
Summary
Nurses are increasingly using evidence-based practice (EBP) to improve patient and organizational outcomes. This article guides clinicians on documenting EBP projects to share these improvements more widely.
Area of Science:
- Nursing
- Healthcare Management
- Evidence-Based Practice
Background:
- Nurses increasingly implement evidence-based practice (EBP) changes within healthcare teams.
- These EBP initiatives demonstrate improvements in patient, family, staff, organizational, and community outcomes.
- Many successful EBP projects are underreported, limiting their broader impact.
Purpose of the Study:
- To provide guidance to clinicians on comprehensively documenting evidence-based practice (EBP) projects.
- To detail the essential steps of the EBP process for effective reporting.
- To align documentation guidelines with criteria for the Evidence-Based Practice Award.
Main Methods:
- The article outlines a structured approach to documenting EBP projects.
- It covers the entire EBP process from problem identification to evaluation.
- Guidelines are presented based on established criteria for nursing research awards.
Main Results:
- Comprehensive documentation of EBP projects can facilitate knowledge sharing.
- Detailed reporting enables the replication and scaling of successful interventions.
- Standardized documentation enhances the visibility and impact of nursing EBP.
Conclusions:
- Effective documentation of EBP projects is crucial for advancing healthcare.
- Sharing detailed EBP project steps allows for wider adoption and improved outcomes.
- This guidance supports nurses in disseminating their EBP innovations.