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

Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...

Documentation of Nursing Diagnosis

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...

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Data Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Types of Records I: Unit and Nurses Records

Types of Records I: Unit and Nurses Records

Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...

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.

You might also read

Related Articles

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

Sort by

Same author

Bridging the SME reporting gap: A new model for predicting Scope 1 and 2 emissions.

Journal of industrial ecology·2026

Same author

Estimating carbon footprints from large scale financial transaction data.

Journal of industrial ecology·2026

Same author

Bridging the climate mitigation gap with economy-wide material productivity.

Journal of industrial ecology·2026

Same author

Quantifying the energy and emissions implications of consumption redistribution in the UK through sustainable consumption corridors.

Scientific reports·2025

Same author

Comprehensive Physical Examination of the Hip.

Video journal of sports medicine·2025

Same author

Health care's response to climate change: a carbon footprint assessment of the NHS in England.

The Lancet. Planetary health·2021

Same journal

Compassion fatigue among critical care nurses: a literature review.

Nursing management (Harrow, London, England : 1994)·2026

Same journal

Repositioning entrepreneurial competence as a core nursing capability: unlocking nurses' leadership and innovation potential.

Nursing management (Harrow, London, England : 1994)·2026

Same journal

How to design and deliver a nurse fellowship.

Nursing management (Harrow, London, England : 1994)·2026

Same journal

Relationship between leadership transparency and workplace cynicism among nurses: a systematic review and meta-analysis.

Nursing management (Harrow, London, England : 1994)·2026

Same journal

Strengthening nurses' recognition of, and response to, domestic violence and abuse.

Nursing management (Harrow, London, England : 1994)·2026

Same journal

From strain to strength: enhancing the benefits of employing temporary nurses.

Nursing management (Harrow, London, England : 1994)·2026

See all related articles

Search research articles

Related Experiment Video

Updated: May 15, 2026

Using Learning Outcome Measures to assess Doctoral Nursing Education

Using Learning Outcome Measures to assess Doctoral Nursing Education

Published on: June 21, 2010

Measuring the nursing contribution using electronic records.

Gill onham¹, Barbara Heyes, Anne Owen

¹Department of Health Informatics. gill.stonham@nhs.net

Nursing Management (Harrow, London, England : 1994)

|January 5, 2013

Summary

This summary is machine-generated.

This study highlights the need for better nursing informatics to capture the quality and performance of patient care. Enhanced data collection and nursing leadership in information management are crucial for demonstrating nursing

More Related Videos

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Published on: September 18, 2018

Related Experiment Videos

Last Updated: May 15, 2026

Using Learning Outcome Measures to assess Doctoral Nursing Education

Using Learning Outcome Measures to assess Doctoral Nursing Education

Published on: June 21, 2010

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Published on: September 18, 2018

Area of Science:

Nursing
Health Informatics
Healthcare Quality Improvement

Background:

Increasing demand for evidence-based patient care outcomes.
Need to quantify nursing's contribution to quality and performance metrics.
Current limitations in patient record systems for integrated care.

Purpose of the Study:

To examine the impact of data demonstration on the nursing profession.
To identify necessary improvements in patient records for future integrated care.
To explore the role of nurses in data collection and information management.

Main Methods:

Review of information management processes and care indicators.
Analysis of patient record requirements for integrated care.
Examination of nursing roles in data collection and nursing classifications.

Main Results:

Description of information management processes and measurement indicators.
Identification of required patient record enhancements for integrated care.
Discussion of nursing classifications and nurse data collector roles.

Conclusions:

Strong nursing leadership in informatics is essential.
Need to influence and shape data collection for accurate representation of nursing care.
Ensuring professional nursing contributions are captured through improved informatics.