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Nursing Clinical Information System

Nursing 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:

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...

Longitudinal Studies

Longitudinal Studies

Longitudinal studies are also widely used in other medical and social science fields. For instance, in cardiovascular research, they can monitor patients' health over decades to identify risk factors for heart disease, such as high cholesterol or smoking, and evaluate the long-term effectiveness of preventive measures. Similarly, in mental health studies, researchers might follow individuals from adolescence into adulthood to understand the development and progression of conditions like...

Formats for Nursing Documentation

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...

Methods of Documentation II: POMR

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

Flow Sheet

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:

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Related Experiment Video

Updated: May 9, 2026

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

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

Published on: September 20, 2018

Navigating longitudinal clinical notes with an automated method for detecting new information.

Rui Zhang¹, Serguei Pakhomov, Janet T Lee

¹Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.

Studies in Health Technology and Informatics

|August 8, 2013

Summary

Automated methods using statistical language models can quantify new information in clinical notes. This approach helps identify clinically significant events and improve clinician efficiency in patient care.

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Published on: July 27, 2018

Area of Science:

Clinical informatics
Natural Language Processing
Health data science

Background:

Clinical notes contain vital patient information but are challenging to navigate.
Automated methods are needed to efficiently extract new information from longitudinal patient records.

Purpose of the Study:

To evaluate statistical language models for quantifying new information in clinical notes.
To assess the relationship between new information proportion (NIP) and clinical significance.

Main Methods:

Statistical language models were developed using longitudinal clinical notes.
The new information proportion (NIP) was calculated for target notes.
NIP trends and correlations with clinical events were analyzed.

Main Results:

NIP decreased logarithmically with the number of prior notes used for model creation.
New information content exhibited cyclic patterns within patient records.
Higher NIP scores correlated with clinically significant events, while lower scores indicated routine updates.

Conclusions:

Automated quantification of new information in clinical notes is feasible.
This method can help clinicians identify key information and improve review efficiency.
Widespread "copy-pasting" practices in note generation were identified.