Related Concept Videos
01:27Nursing 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:
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:
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.
01:10Documentation 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...
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...
01:18Guidelines 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:
Maintain Confidentiality and Security:
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
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:
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.
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E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
Published on: August 1, 2019
[Nurses' perception regarding the implementation of computer-based clinical nursing documentation].
Antonio Fernandes Costa Lima1, Talita de Oliveira Melo
1Departamento de Orientação Profissional, Escola de Enfermagem, Universidade de São Paulo, SP, Brasil. tonifer@usp.br
Revista Da Escola De Enfermagem Da U S P
|March 24, 2012
Summary
Nurses piloting the PROCEnf-USP electronic system perceived its preliminary use positively. This engagement fostered improvements and encouraged nurses to become partners in disseminating the computerized clinical documentation system.
Area of Science:
- Nursing Informatics
- Health Information Systems
- Qualitative Research Methods
Context:
- University hospital medical-surgical units
- Pilot testing of a new electronic system
- Computerization of clinical nursing documentation
Purpose:
- Understand nurses' perceptions of strategies for piloting the PROCEnf-USP system
- Identify favorable and unfavorable aspects of implementation
- Explore nurses' expectations for the electronic system
Summary:
- Qualitative study involving 11 nurses in a theoretical-practical training program
- Data analyzed using Content Analysis Technique
- Identified themes: favorable aspects, unfavorable aspects, and expectations
Impact:
- Nurses' engagement led to system improvement suggestions
- Empowered nurses to become advocates for electronic documentation
- Facilitated broader institutional adoption of the PROCEnf-USP system