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The Case for Standardized Data in Nursing
1Project Director, C-HOBIC, President, Canadian Nursing Informatics Association, Toronto, ON.
Abstract:
With the increased focus on quality and safety within the healthcare system, the collection, reporting and use of standardized data are essential to understanding the impact of clinicians practice on patient care. This article examines how the Canadian Health Outcomes for Better Information and Care (C-HOBIC) dataset can support clinical decision-making and facilitate improved sharing of information as patients transition between sectors of the healthcare system. If the benefits of electronic health records are to be fully realized, it is vital that information is collected in a standardized format to support point-of-care clinicians in decision-making, as well as for health system use.
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Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Nursing Assessment
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments...
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