Search research articles

ABOUT JoVE

Overview Leadership Blog JoVE Help Center

AUTHORS

Publishing Process Editorial Board Scope & Policies Peer Review FAQ Submit

LIBRARIANS

Testimonials Subscriptions Access Resources Library Advisory Board FAQ

RESEARCH

JoVE Journal Methods Collections JoVE Encyclopedia of Experiments Archive

EDUCATION

JoVE Core JoVE Business JoVE Science Education JoVE Lab Manual Faculty Resource Center Faculty Site

Terms & Conditions of Use

Related Concept Videos

Formats for Nursing Documentation

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...

Guidelines for Nursing Documentation II

Guidelines 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.

Legal Guidelines for Documentation

Legal 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:

Guidelines for Nursing Documentation I

Guidelines 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.

Introduction to Documentation and Reporting

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...

Guidelines and Strategies for Safe Computer Charting

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:

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by

Same author

Informing the Measurement of Timely Follow-Up on Inconclusive or Abnormal Screening Mammograms: An Environmental Scan.

Joint Commission journal on quality and patient safety·2026

Same author

Patient-reported symptom assessments and early chemotherapy discontinuation in routine gastrointestinal cancer care.

Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer·2026

Same author

Heart-lung transplantation in the United Kingdom: Trends and outcomes over 4 decades.

JHLT open·2026

Same author

Before we Build: The Missing Use Case in Nursing AI Enthusiasm.

Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing·2026

Same author

Feasibility of ontology-guided structuring of stress information from narrative text: An exploratory study using large language models.

Digital health·2026

Same author

Author Correction: Real-time surveillance system for patient deterioration: a pragmatic cluster-randomized controlled trial.

Nature medicine·2026

Search research articles

Related Experiment Video

Updated: Jun 8, 2026

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Published on: July 12, 2024

A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system.

Hyeoneui Kim¹, Patricia C Dykes, Debra Thomas

¹Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, 9500 Gilman Drive #0671, La Jolla, CA 92093-0671, USA. hyeoneui@ucsd.edu

Computers in Biology and Medicine

|September 18, 2010

Summary

A documentation analysis identified issues with paper patient records. These problems, including redundancy and lack of structure, must be addressed for a new computerized nursing documentation system.

More Related Videos

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Related Experiment Videos

Last Updated: Jun 8, 2026

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Published on: July 12, 2024

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Area of Science:

Nursing Informatics
Healthcare Documentation Systems

Background:

Current paper-based patient records at a large teaching hospital present challenges.
Preparation for a new computerized documentation system necessitates analysis of existing records.

Purpose of the Study:

To analyze the medical and surgical nursing content within the current paper patient record.
To identify problems in the existing documentation that need resolution in a future computerized system.

Main Methods:

A small-scale documentation analysis was performed.
The study focused on patient records at a teaching hospital affiliated with Partners Healthcare System (PHS).

Main Results:

Identified significant documentation redundancy in the paper record.
Highlighted areas requiring more structure to accurately capture nursing practice data.
Noted various design considerations for improved computerized documentation.

Conclusions:

The transition to a computerized system requires addressing identified issues.
Enhancing structure and reducing redundancy are crucial for accurate nursing care documentation.
Design considerations are vital for a complete and effective computerized nursing documentation system.