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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:
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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:
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Related Experiment Video

Updated: Sep 14, 2025

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

Developing a Medication Administration Observation Checklist: Key Insights for Standardized Reporting Methodology.

Madison Hickey¹, Brittany V Barber, Chloe Flynn

¹Author Affiliations: School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada (Ms Hickey, Dr Barber, Ms Keeping); and Quality and Patient Safety Research, Izaak Walton Killam (IWK) Health, Halifax, Nova Scotia, Canada (Mss Doig, Bercovici, Drs Sinclair, Curran).

Journal of Nursing Care Quality

|July 24, 2025

Summary

This study developed a medication administration observation checklist for a pediatric tertiary care center. Co-development with nurses ensures a relevant and usable tool to improve patient safety in medication administration.

Keywords:

medication administration nursing observation tools patient safety systems engineering

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A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings

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Published on: November 9, 2016

Area of Science:

Nursing
Patient Safety
Health Informatics

Background:

Medication administration incidents pose a significant patient safety risk.
Human and work system factors are key contributors to medication errors.

Purpose of the Study:

To develop a medication administration observation checklist tool.
The tool is specifically tailored for a pediatric tertiary care center in Atlantic Canada.

Main Methods:

Synthesized existing evidence on observational tools for medication administration.
Engaged nursing knowledge users in Think Aloud sessions for iterative refinement of the checklist.

Main Results:

Developed a medication administration observation checklist tool.
Incorporated feedback from frontline nurses and nurse managers.
Ensured the checklist's relevance and usability in clinical practice.

Conclusions:

Co-developing data collection tools with interdisciplinary teams is crucial.
Leveraging theoretical frameworks aids in capturing workflow complexities.
Enhancing transparency in reporting methodologies supports replicability.