Related Experiment Video
Updated: Apr 5, 2026
Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
Nursing Clinical Documentation System Structured on NANDA-I, NOC, and NIC Classification Systems
Heloisa Helena C Peres1, Diná de Almeida Lopes M da Cruz1, Michelle Tellez2
1School of Nursing, University of Sao Paulo, Brazil.
Abstract:
Information is a key feature that health professionals need to exercise their profession with efficiency and quality. This study aims to present the experience of the usage of an electronic system for clinical documentation in nursing in a university hospital. It is a methodological research of technology production. The system was developed in four phases: Conception, Elaboration, Construction, and Transition, and was named Electronic Documentation System of the University of São Paulo Nursing Process (PROCEnf-USP™). The knowledge base of PROCEnf-USP™ was organized in hierarchy of domains and classes, according to NNN linkages.
More Related Videos
07:50A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
06:04Objective Nociceptive Assessment in Ventilated ICU Patients: A Feasibility Study Using Pupillometry and the Nociceptive Flexion Reflex
Published on: July 4, 2018
Related Concept Videos
01:27Nursing Clinical Information System
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:
01:29Nursing Interventions II: Selecting and Classifying the Nursing Interventions
01:26Guidelines for Nursing Documentation II
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.
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:28Formats for Nursing Documentation
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,...
01:10Documentation of Nursing Diagnosis
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...