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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.

Guidelines for Nursing Documentation II

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.

Methods of Documentation III: PIE

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:

Methods of Documentation I: Source-Oriented Records

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

Methods of Documentation VI: Case Management Model

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...

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.

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Related Experiment Video

Updated: May 5, 2026

Intraoperative Video Consultation Following Bile Duct Transection Facilitates Direct OR Transfer for Robotic Hepaticojejunostomy at Tertiary Center

Intraoperative Video Consultation Following Bile Duct Transection Facilitates Direct OR Transfer for Robotic Hepaticojejunostomy at Tertiary Center

Published on: January 9, 2026

Does perioperative documentation transfer reliably?

Jamie Ridout¹, Julia Aucoin, Anne Browning

¹Author Affiliations: Duke University Health System (Ms Ridout) and Duke University Health System (Dr Aucoin, Mss Browning, Piedra, and Weeks), Durham, North Carolina.

Computers, Informatics, Nursing : CIN

|December 10, 2013

Summary

Patient information transfer failures occur in 10.2% of cases during the perioperative process. Consistent communication methods are crucial to minimize risks, especially without comprehensive electronic health records.

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Last Updated: May 5, 2026

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Area of Science:

Perioperative Medicine
Healthcare Communication
Patient Safety

Background:

Effective information transfer is critical for patient safety in the multiphasic perioperative process.
Previous research highlights the importance of communication in minimizing perioperative risks.
Opportunities for information exchange exist between providers and across different healthcare settings.

Purpose of the Study:

To determine the incidence of failures in communicating vital patient information throughout the six phases of the perioperative process.
To quantify the rate of communication breakdowns in ambulatory surgery settings.
To identify areas for improvement in perioperative information exchange.

Main Methods:

Systematic sampling of ambulatory surgery patient records.
Analysis of patient records over a one-quarter period.
Calculation of the failure-to-communicate rate based on recorded entries.

Main Results:

A failure-to-communicate rate of 10.2% was identified among 5586 patient record entries.
Significant opportunities for information transfer exist but are not consistently utilized.
The study highlights a notable incidence of missed or incomplete vital information transfer.

Conclusions:

A substantial percentage of perioperative processes experience failures in vital information communication.
The absence of a comprehensive electronic health record necessitates standardized information transfer protocols.
Implementing consistent communication methods is essential for risk mitigation in perioperative care.