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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.
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Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

Methods of Documentation VI: Case Management Model

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Nursing Clinical Information System

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
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Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

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Published on: September 26, 2018

Computerizing clinical patient problems: an evolving tool for medical education.

G C Pickell, D Medal, W S Mann

Medical Education

|May 1, 1986

Summary

A high-fidelity patient simulation was developed using affordable microcomputers. This flexible tool supports problem-based learning and assesses data management and clinical reasoning skills for students.

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Area of Science:

Medical Education Technology
Health Professions Education
Simulation-Based Learning

Background:

Traditional medical education methods face challenges in providing realistic clinical experience.
There is a need for accessible and adaptable training tools for healthcare professionals.
Developing cost-effective simulation technologies is crucial for widespread adoption.

Purpose of the Study:

To develop a high-fidelity patient simulation using low-cost microcomputer technology.
To create a flexible and responsive simulation adaptable to individual learning needs.
To evaluate the utility of the simulation in assessing data management and clinical reasoning skills.

Main Methods:

Developed a natural language, free-enquiry patient simulation.
Utilized low-cost microcomputer technology for accessibility and portability.
Based the design on principles of problem-based, self-directed learning.

Main Results:

The simulation is flexible, portable, and responsive to student needs.
It does not require prior computer literacy from users.
Demonstrated usefulness in both individual and group learning settings.

Conclusions:

The developed patient simulation offers a cost-effective, high-fidelity learning tool.
It effectively supports problem-based learning and enhances clinical reasoning skills.
The simulation is a valuable resource for medical education and skills assessment.