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Related Concept Videos

Role of Communication in the Nursing Process III: Evaluation and Documentation01:08

Role 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:
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.
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...
Formats for Nursing Documentation01:28

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...
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...

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Related Experiment Video

Updated: May 19, 2026

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
14:32

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

Published on: February 16, 2011

Achieving IT-supported standardized nursing documentation through participatory design.

Stine Loft Rasmussen1, Karen Marie Lyng, Sanne Jensen

  • 1Department of Health Science, University of Copenhagen, Denmark. stine.loft.rasmussen@regionh.dk

Studies in Health Technology and Informatics
|August 10, 2012
PubMed
Summary

A pilot project in Denmark demonstrated that IT-supported nursing documentation, using participatory design (PD), yielded promising results. This approach enhanced standard documentation templates, improving nurses' daily work and coordination.

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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Human-Computer Interaction

Background:

  • Implementing IT-supported nursing documentation in large healthcare organizations presents challenges.
  • Standardized, guideline-based documentation is crucial for quality care and coordination.
  • Engaging diverse stakeholders is key to successful system adoption.

Purpose of the Study:

  • To discuss participatory design (PD) as a method for creating effective clinical documentation templates.
  • To explore how PD can support guideline-based, structured documentation in a complex environment.
  • To present findings from a pilot project on IT-supported nursing documentation.

Main Methods:

  • Utilizing participatory design (PD) across multiple organizational levels.
  • Developing a set of design principles to guide stakeholder discussions.
  • Implementing standard documentation templates based on PD and design principles.

Main Results:

  • The pilot project, running for two months at a university hospital, showed promising results.
  • Participatory design actively involved stakeholders in the template design process.
  • The developed templates effectively support nurses' daily work and inter-nurse coordination.

Conclusions:

  • Participatory design is an effective method for developing IT-supported clinical documentation templates.
  • Design principles are instrumental in facilitating stakeholder consensus and successful implementation.
  • IT-supported nursing documentation, designed with PD, can significantly improve healthcare coordination.