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Nursing Assessment

Nursing Assessment

The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments...

Formats for Nursing Documentation

Formats for Nursing Documentation

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,...

Fundamentals of Nursing Process I

Fundamentals of Nursing Process I

The nursing process is the core of practice for every registered nurse to deliver holistic, patient-focused care. The following are the five steps in the nursing process.

Methods of Documentation II: POMR

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

Fundamentals of Nursing Process II

Fundamentals of Nursing Process II

There are several characteristics related to delivering nursing care. One vital characteristic of the nursing process is that it can be used to protect nurses and justify the provided care. Productive use of the nursing process requires the knowledge and skills of nurses to assess and solve issues. Nurses should develop and strengthen their critical thinking skills and evidence-based nursing interventions to improve their skills in formulating nursing care plans. A well-defined approach to...

Methods of Documentation VI: Case Management Model

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...

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Related Experiment Video

Updated: Sep 22, 2025

Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments

Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments

Published on: August 8, 2019

Process Mining of Nursing Routine Data: Cool, but also Useful?

Julian Jonk^1,2, Michael Schaller¹, Michael Netzer¹

¹UMIT TIROL - Private University for Health Sciences, Medical Informatics and Technology, Institute of Medical Informatics, Hall in Tirol, Austria.

Studies in Health Technology and Informatics

|May 20, 2022

Summary

Process mining in gerontopsychiatry shows care process variations but struggles to detect delirium. Routine data analysis is feasible, but interpretation requires refinement for clinical insights.

Keywords:

Data Mining Delirium Delivery of Health Care Process Assessment

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Area of Science:

Healthcare Data Analytics
Process Mining Applications

Background:

Process mining, a data analytics technique, has potential in healthcare for improving care quality, patient safety, and cost-efficiency.
Its application in gerontopsychiatric settings remains underexplored.

Purpose of the Study:

To investigate the emergence and detectability of delirium using process mining in a gerontopsychiatric environment.
To gain longitudinal insights into patient care pathways.

Main Methods:

Utilized process mining to construct models from anonymized nursing data from two gerontopsychiatric wards.
Analyzed process models to understand the longitudinal progression of care activities.

Main Results:

Process models encompassed all patient stay activities but were complex and difficult to interpret due to diverse care paths.
Frequent care paths and activities were identified, but delirium emergence could not be meaningfully explained.
No significant differences were detected between patient stays with or without delirium.

Conclusions:

Process mining of routine data is straightforward, but result interpretation poses challenges.
Identified four limitations in using routinely collected data for this analysis.
Provided recommendations for data adaptation to enhance future process mining studies in healthcare.