Related Concept Videos
01:20Introduction 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...
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...
01:29Documentation in Long-Term and Home Healthcare Setting
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
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.
01:06Legal 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:
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:
01:26Methods 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.
You might also read
Related Articles
Articles linked to this work by shared authors, journal, and citation graph.
Sort by
Same author
Define Your Pressure Injury Clinical Order Set within Your Workflow.
Advances in skin & wound care·2021
Same author
Diabetic Foot Ulcer Assessment and Management: Use of Classification Systems for Healing Progress.
Advances in skin & wound care·2020
Same author
Venous Ulcer Assessment and Management: Using the Updated CEAP Classification System.
Advances in skin & wound care·2020
Related Experiment Video
Updated: May 7, 2026
03:47
Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients
Published on: July 12, 2024
Processes + workflows drive documentation compliance
1Cathy Thomas Hess, BSN, RN, CWOCN, is Vice President and Chief Clinical Officer, Net Health. Ms Hess presides over Professional Services, which offers products and solutions to optimize processes and workflows.
Advances in Skin & Wound Care
|September 19, 2013
Summary
No abstract available in PubMed .
