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Related Concept Videos

Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

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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.
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Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
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Formats for Nursing Documentation01:28

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Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
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• It includes patient demographics, medical history,...
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Documentation of Nursing Diagnosis01:10

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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.
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Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

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Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
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Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

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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.
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ESCMID white paper: a guide on ESCMID guidance documents.

L Scudeller1, J Rodríguez-Baño2, A Zinkernagel3

  • 1IRCCS Policlinic San Matteo Foundation, Pavia, Italy.

Clinical Microbiology and Infection : the Official Publication of the European Society of Clinical Microbiology and Infectious Diseases
|August 27, 2018
PubMed
Summary

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) clarifies terminology and format for its guidance documents. This ensures consistent, high-quality scientific and medical guidance in infectious diseases.

Keywords:
Consensus methodsConsensus statementsGuidelinesPosition paperState-of-the-art

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Area of Science:

  • Clinical Microbiology and Infectious Diseases
  • Medical and Scientific Guidance

Background:

  • The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) seeks to enhance its international role in providing medical and scientific guidance.
  • Numerous guidance documents exist within the field, necessitating standardized terminology and formats.

Purpose of the Study:

  • To clarify the terminology and format for ESCMID guidance documents submitted to Clinical Microbiology and Infection (CMI).
  • To highlight the core principles underpinning the development of ESCMID guidance documents.

Main Methods:

  • Identification and categorization of five distinct types of ESCMID guidance documents: White Papers, Clinical Practice Guidelines, Consensus Statements, State-of-the-Science Statements, and Position Papers.
  • Description of variations in scope, development methods, drafting group composition, and publication formats for each document type.
  • Emphasis on the requirement for full disclosure of potential conflicts of interest for all drafting group members.

Main Results:

  • ESCMID guidance documents serve as a foundational resource for professionals in related fields.
  • These documents are crucial for education and training within the scientific community.
  • The development process for guidance documents is a scientific endeavor requiring transparency and multidisciplinary collaboration.

Conclusions:

  • Standardized terminology and formats are essential for ESCMID guidance documents.
  • A transparent and rigorous development process is critical for producing high-quality scientific guidance.
  • ESCMID guidance documents play a vital role in advancing clinical microbiology and infectious diseases research and practice.