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Related Concept Videos

Methods of Documentation III: PIE01:21

Methods 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:
Guidelines for Nursing Documentation II01:26

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 Documentation01:06

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:
Introduction to Documentation and Reporting01:20

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 for Nursing Documentation I01:30

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.
Documentation of Nursing Diagnosis01:10

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...

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Related Experiment Video

Updated: May 21, 2026

The Participant-Reported Implementation Update and Score (PRIUS): A Novel Method for Capturing Implementation-Related Data Over Time
06:05

The Participant-Reported Implementation Update and Score (PRIUS): A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

Lessons learned from implementation of a perinatal documentation system.

Chia-An Chao, Joanne Goldbort

    Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN
    |June 14, 2012
    PubMed
    Summary

    Implementing electronic medical record (EMR) systems in hospitals is complex. While EMRs did not change patient care, nurses reported more negative perceptions after implementation.

    Keywords:
    before and after comparisonelectronic medical recordlessons learnedperinatal nursing

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    Published on: October 25, 2015

    Area of Science:

    • Healthcare Informatics
    • Clinical Systems Implementation
    • Perinatal Care Technology

    Background:

    • Electronic Medical Record (EMR) systems are increasingly adopted in healthcare settings.
    • Implementation is a complex, multi-stage process with significant organizational impact.
    • Previous studies highlight varied outcomes and user experiences with EMR adoption.

    Purpose of the Study:

    • To detail the critical steps and challenges in implementing an EMR system within a Midwestern hospital's perinatal unit.
    • To evaluate the impact of EMR implementation on patient care activities and clinician communication.
    • To assess changes in nurses' perceptions following the EMR system's introduction.

    Main Methods:

    • A case study approach was used in a Midwestern hospital's perinatal setting.
    • Key implementation phases included strategic planning, governance, requirements analysis, vendor selection, and training.
    • Pre- and post-implementation data were collected to compare patient care activities, clinician communication, and user perceptions.

    Main Results:

    • The EMR implementation process involved distinct stages: planning, structure, requirements, vendor selection, and training.
    • No significant differences were observed in patient care activities or inter-clinician communication before and after EMR implementation.
    • Nurses' perceptions of the EMR system became more negative post-implementation.

    Conclusions:

    • EMR implementation requires meticulous planning and execution across multiple critical steps.
    • While EMRs may not directly alter care processes or communication, user perception is a crucial factor for successful adoption.
    • Hospitals should address potential negative user perceptions through targeted training and support during and after EMR rollout.