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Documentation of Nursing Diagnosis

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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...

Planning Nursing Care I

Planning Nursing Care I

The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...

Documentation in Long-Term and Home Healthcare Setting

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities

Discharge Summary Forms

Discharge Summary Forms

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
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Traditional Level Of Health Care System

Traditional Level Of Health Care System

The levels of care describe the services provided in the healthcare system. Accordingly, there are six levels of the traditional healthcare system in the US: preventive, primary, secondary, tertiary, restorative, and continuing healthcare. A nurse must understand how the healthcare industry organizes and provides services within these levels of care.
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Secondary Healthcare System

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Secondary healthcare is offered by a specialist, generally in hospitals or clinics for patients referred by primary healthcare providers. It occurs when a person has an illness or injury that requires specific medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a minor laceration or treat a strep throat infection to more complicated emergent care, such as treating a head injury sustained in an automobile accident. Whatever...

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Related Experiment Video

Updated: Feb 25, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Published on: September 30, 2020

Unplanned Returns to Hospital Care: A Linked Data Study.

Kathy Smith¹, Renee Iannotti¹

¹Health System Information and Performance Reporting Branch, NSW Ministry of Health.

Studies in Health Technology and Informatics

|July 31, 2017

Summary

Linking healthcare data offers a full patient journey view. New methods are needed to accurately measure unplanned returns to care, as current approaches are insufficient.

Keywords:

Representations admitted patients data linkage emergency departments indicators journeys of care measurement readmissions

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Last Updated: Feb 25, 2026

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

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Published on: September 30, 2020

Inverse Probability of Treatment Weighting Propensity Score using the Military Health System Data Repository and National Death Index

Inverse Probability of Treatment Weighting Propensity Score using the Military Health System Data Repository and National Death Index

Published on: January 8, 2020

Area of Science:

Health Services Research
Public Health
Health Informatics

Background:

Integrated patient data across healthcare settings provides a comprehensive view of patient care.
Measuring unplanned returns to care is crucial for assessing healthcare quality and efficiency.
Existing methods for tracking unplanned returns may not fully capture the scope of these events.

Purpose of the Study:

To review alternative data linkage approaches for measuring unplanned returns to care.
To evaluate current measurement strategies for unplanned returns in New South Wales (NSW) public hospitals.
To highlight the need for improved measurement using integrated health information.

Main Methods:

Utilized data linkage across NSW public hospital emergency departments and admitted patient care settings.
Reviewed and compared different methodologies for quantifying unplanned returns to care.
Analyzed the extent to which current measures identify all unplanned return events.

Main Results:

Existing measures of unplanned returns to care underestimate the true incidence of these events.
Data linkage reveals a more complete picture of patient readmissions and emergency revisits.
Current measurement approaches fail to capture the full extent of unplanned returns.

Conclusions:

Current methods for measuring unplanned returns to care are inadequate.
Integrated patient data offers opportunities for more accurate measurement of healthcare utilization.
Development of new measurement approaches is essential to understand and improve patient care pathways.