Creating Our Professional Evidence-Base: A Journey, Not a Destination

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...

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

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...

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...

The scientific method provides the foundation for any research. It is the most reliable and objective of all forms of gaining knowledge and guides in applying research-based evidence in practice and conducting future research.
When using research findings to change practice, one must understand the process used to guide a study. The scientific method is a systematic, step-by-step process that supports the data's validity, reliability, and generalizability. As a result, findings can be...

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning,...