Related Experiment Video
Updated: May 4, 2026
08:13
Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
6.4K
Defining and incorporating basic nursing care actions into the electronic health record
Jane Englebright1, Kelly Aldrich, Cathy R Taylor
1Iota, Chief Nursing Officer & Vice-President, Clinical Services Group, HCA, Nashville, TN.
Summary
Defining basic nursing care for hospitalized adults is achievable. Implementing this definition in electronic health records improves documentation and clarity of essential patient care activities.
Area of Science:
- Nursing Science
- Health Informatics
Background:
- Basic nursing care is fundamental to hospitalized adult patient well-being.
- A clear, standardized definition of basic nursing care is needed for consistent practice and documentation.
Purpose of the Study:
- To establish a precise definition of basic nursing care for hospitalized adult patients.
- To integrate this definition into an electronic health record (EHR) system to enhance its adoption.
Main Methods:
- A multidisciplinary team, including direct care nurses and subject matter experts, analyzed nursing theory and regulatory standards.
- Identified basic nursing care activities were coded using the Clinical Care Classification (CCC) system.
- The CCC-coded activities were incorporated into a 170-bed community hospital's EHR system.
Main Results:
- Ten basic nursing care activities were defined through theoretical analysis and pilot EHR implementation.
- The hospital successfully passed a regulatory review post-implementation concerning basic patient care documentation.
- The EHR system facilitated improved clarity, documentation, and communication of basic care elements.
Conclusions:
- Defining basic nursing care is feasible and distinct from interdisciplinary care plans.
- EHR integration aids in clarifying, documenting, and communicating essential nursing care.
- This initiative is a foundational step towards leveraging data for improved patient outcomes and collaborative processes.
Related Concept Videos
01:30Methods of Documentation VII: EMR
1.5K
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...
1.5K
01:28Formats for Nursing Documentation
2.1K
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,...
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,...
2.1K
01:18Guidelines and Strategies for Safe Computer Charting
1.9K
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
1.9K
01:15Nursing Implementation
6.3K
Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
6.3K
01:26Guidelines for Nursing Documentation II
2.0K
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.
2.0K
01:06Legal Guidelines for Documentation
2.4K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
2.4K