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 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:

Flow Sheet

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:

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:

Methods of Documentation IV: Focus Charting

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Data Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

You might also read

Related Articles

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

Sort by

Same author

Occupational bladder cancer: A cross section survey of previous employments, tasks and exposures matched to cancer phenotypes.

PloS one·2020

Same author

Impact of Anaesthetist Volume on Radical Cystectomy Outcomes.

European urology focus·2019

See all related articles

Search research articles

Related Experiment Video

Updated: Mar 27, 2026

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Published on: September 26, 2018

Improving the medical 'take sheet'.

¹Belfast City Hospital.

BMJ Quality Improvement Reports

|January 7, 2016

Summary

This summary is machine-generated.

A new medical handover proforma improved patient care continuity. The revised template enhanced information transfer, ensuring safer patient handovers between doctors in hospital settings.

More Related Videos

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Related Experiment Videos

Last Updated: Mar 27, 2026

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Published on: September 26, 2018

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Area of Science:

Medical Education
Patient Safety
Healthcare Management

Background:

Hospital trainees require organized handover for patient care continuity as per GMC guidelines.
Multiple daily medical admissions via various routes (GP, tertiary transfer, bed shortages) at Belfast City Hospital complicate information transfer.
Current medical take sheets offer limited space, risking loss of critical patient data during handover between doctors.

Purpose of the Study:

To improve the existing medical handover proforma used for new admissions and transfers.
To enhance the identification of sick patients and ensure continuity of care.
To address deficiencies in the current handover process identified by hospital trainees.

Main Methods:

An initial questionnaire assessed the usability and effectiveness of the old handover proforma.
Feedback from Senior House Officers (SHOs) and Registrars informed the creation of a new template.
A repeat questionnaire evaluated the impact of the newly trialled proforma on handover quality.

Main Results:

Initial survey: 47% found the old proforma easy to use; 28.2% felt it helped identify sick patients.
100% of surveyed SHOs and Registrars believed the proforma could be improved.
Post-implementation survey: 92.3% felt the new format improved medical handover; 92.6% reported it allowed safe handover most/all of the time.

Conclusions:

The redesigned medical handover proforma significantly improved the quality and safety of patient handovers.
The new template addresses the limitations of the previous system, facilitating better information exchange.
The successful trial led to the permanent implementation of the improved proforma for all new medical admissions and transfers.