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Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
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Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation01:20

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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,...
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Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis01:24

Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis

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The nursing process provides a clinical decision-making framework for patients and families to establish and implement a personalized care plan. Since part of the nurse's duties is to teach patients, the steps of the nursing process are the most effective way to approach instruction. The nursing process and the teaching-learning process are inextricably linked.
It is critical to determine the patient's learning needs during the assessment. Determination of learning needs compounds data...
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Nursing Evaluation01:15

Nursing Evaluation

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The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.
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Flow Sheet01:17

Flow Sheet

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Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
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Nursing Implementation01:15

Nursing Implementation

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Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
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Updated: Sep 14, 2025

Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults
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Tools for Assessing Medication Safety Processes in Nursing Homes: A Systematic Review.

Ramesh Sharma Poudel1, Kylie A Williams, Lisa G Pont

  • 1Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.

Journal of Patient Safety
|July 23, 2025
PubMed
Summary
This summary is machine-generated.

This review identified four tools for measuring medication safety in nursing homes. The Canadian Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) demonstrated the broadest scope and highest quality.

Keywords:
medication safetynursing homespatient safetytool

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Area of Science:

  • Gerontology
  • Health Services Research
  • Patient Safety

Background:

  • Medication safety in nursing homes is a critical concern for resident well-being.
  • Existing tools for assessing medication safety processes vary in scope and quality.

Purpose of the Study:

  • To systematically identify and evaluate tools for measuring medication safety-related processes in nursing homes.

Main Methods:

  • Systematic search of Medline, Embase, and CINAHL databases up to June 2022.
  • Mapping tool items to the medication management pathway (9 steps, 3 background processes).
  • Assessing methodological quality using the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument.

Main Results:

  • Four tools were identified, exhibiting significant variation in development, content, focus, and quality.
  • The Canadian Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) was the only tool to cover all medication management pathway components.
  • MSSA-LTC also received a high overall quality rating according to the AIRE instrument.

Conclusions:

  • The Canadian MSSA-LTC tool offers the most comprehensive coverage and highest quality among the identified instruments.
  • Selection of a tool should align with the specific assessment purpose, processes of interest, and jurisdictional validity.
  • Understanding tool differences and limitations is crucial for effective implementation in nursing home settings.