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Role of Communication in the Nursing Process III: Evaluation and Documentation

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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:

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Factual:
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Documentation is the systematic process of formally recording, maintaining, and communicating information.
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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

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Communicating evidence in clinical documentation.

Janis Davis¹, Elizabeth Zayat, Maggie Urton

¹Occupational Therapy Education Program, Rockhurst University, Kansas City, Missouri 64110, USA. janis.davis@rockhurst.edu

Australian Occupational Therapy Journal

|October 5, 2010

Summary

Most occupational therapy practitioners support using evidence in patient documentation, especially when funding or department policies require it. This study explored their views on evidence communication.

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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Published on: February 16, 2011

Area of Science:

Health Services Research
Occupational Therapy
Evidence-Based Practice

Background:

Communicating evidence in patient documentation is crucial for occupational therapy practice.
Understanding practitioners' and stakeholders' views is essential for improving evidence integration.

Purpose of the Study:

To investigate occupational therapy practitioners' and stakeholders' attitudes towards evidence communication in patient documentation.
To identify factors influencing the use of evidence in clinical documentation.

Main Methods:

A mixed-methods design incorporating two distinct surveys.
Electronic survey distributed to occupational therapy practitioners in the Midwestern USA.
Delphi survey administered to stakeholders including case managers, supervisors, and payers.

Main Results:

A 29% response rate with 126 surveys analyzed.
63.5% of practitioners affirmed the importance of communicating evidence in documentation.
Strong agreement among clinicians to use evidence when funding or departmental policies mandate it.

Conclusions:

Occupational therapy practitioners recognize the value of evidence in documentation.
External factors like funding and departmental guidelines significantly influence evidence communication in practice.