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Related Concept Videos

Data Collection II01:29

Data Collection II

9.2K
The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and...
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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:
• 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,...
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Guidelines for Nursing Documentation I01:30

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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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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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Introduction to Documentation and Reporting01:20

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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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Data Collection I01:30

Data Collection I

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Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of...
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Related Experiment Video

Updated: Nov 5, 2025

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
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Capturing Nursing History With Creative Writing: Two Exemplars.

Jacqueline K Owens

    Creative Nursing
    |May 15, 2021
    PubMed
    Summary

    Documenting nursing history is vital for practice. This article explores how nurses Terri Arthur and Jeanne Bryner use creative writing, including narrative and poetry, to share nursing stories and historical research.

    Area of Science:

    • Nursing History
    • Creative Writing in Healthcare
    • Scholarly Communication

    Background:

    • Florence Nightingale's foundational documentation of nursing history.
    • The ongoing importance of historical research in guiding nursing practice.
    • The role of nurse scholars in preserving professional narratives.

    Observation:

    • Story-based narratives effectively convey individual nurses' contributions.
    • Creative writing resonates with both nursing professionals and the general public.
    • Two nurses, Terri Arthur and Jeanne Bryner, exemplify successful dissemination of nursing stories.

    Findings:

    • Arthur and Bryner utilize historical narrative, poetry, and reflective prose.
    • Their creative approaches capture and share nursing history.
    Keywords:
    anthologycreative writinghistorical narrativenursing historyoral history

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  • This method enhances the understanding and appreciation of nursing's past.

    • Implications:

    • Creative writing offers a powerful medium for nursing historical research.
    • Disseminating nursing history through narrative can inspire current and future practitioners.
    • This approach bridges the gap between academic research and broader public engagement.