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

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.

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.

Legal Guidelines for Documentation

Legal 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:

Guidelines for Writing Outcome

Guidelines for Writing Outcome

When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...

Guidelines and Strategies for Safe Computer Charting

Guidelines and Strategies for Safe Computer Charting

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:

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning,...

You might also read

Related Articles

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

Sort by

Same author

Use of Evidence-Based Type 2 Diabetes Preventive Therapies and Rates of Progression to Diabetes Among Veterans with Prediabetes by Race and Ethnicity, 2010-2019.

Journal of general internal medicine·2026

Same author

Quality of hospital medicine care in Veterans Affairs hospitals versus non-Veterans Affairs hospitals: A systematic review of comparative studies.

Journal of hospital medicine·2026

Same author

Recruiting US veterans with chronic low back pain in a multisite randomized pragmatic trial.

Trials·2026

Same author

Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians (Version 1, Update Alert 4).

Annals of internal medicine·2026

Same author

Measuring Primary Care Productivity in the Era of Interprofessional Team Care: Stakeholder, Scoping Review, and Implementation Perspectives.

The Milbank quarterly·2025

Same author

Adapting depression collaborative care models to increase uptake of computerized cognitive behavioral therapy at the VA: A pilot randomized controlled trial.

General hospital psychiatry·2025

Same journal

WHO Issues Guidelines for Treating Ebola and Marburg Viruses.

JAMA·2026

Same journal

FDA Approves Additional Naloxone Nasal Spray for Opioid Overdose.

JAMA·2026

Same journal

HIV May Hide in More Cells Than Previously Thought-Here's What That Could Mean for a Cure.

JAMA·2026

Same journal

US Dietary Supplement Use Increasing, Especially in Older Adults.

JAMA·2026

Same journal

Heat Stress From Climate Change Surges Globally.

JAMA·2026

Same journal

Strength Training Linked With Lower Cardiovascular Disease Risk in Women.

JAMA·2026

See all related articles

Search research articles

Related Experiment Video

Updated: Apr 29, 2026

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

Updating practice guidelines

Paul G Shekelle¹

¹VA West Los Angeles Medical Center, Los Angeles, California2RAND Corporation, Santa Monica, California.

|May 29, 2014

Summary

No abstract available in PubMed .

More Related Videos

Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction

Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction

Published on: December 3, 2017

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Related Experiment Videos

Last Updated: Apr 29, 2026

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction

Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction

Published on: December 3, 2017

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012