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Related Concept Videos

Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Formats for Nursing Documentation01:28

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, current medications, vital...
Nursing Clinical Information System01:27

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.
Critical attributes of NCIS include:
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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
Methods of Documentation VI: Case Management Model01:15

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 illness...

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  1. Home
  3. From Unstructured To Structured Nursing Documentation For Myocardial Infarction Patients Using Clinical Practice Guidelines And Snomed Ct.
  1. Home
  3. From Unstructured To Structured Nursing Documentation For Myocardial Infarction Patients Using Clinical Practice Guidelines And Snomed Ct.

Related Experiment Video

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients
03:47

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Published on: July 12, 2024

From Unstructured to Structured Nursing Documentation for Myocardial Infarction Patients Using Clinical Practice

Hyeyoung Lee1, Sumi Sung1, Jungeun Hong1

  • 1College of Nursing, Research Institute of Nursing Science, Chungbuk National University, Cheongju, Republic of Korea.

Studies in Health Technology and Informatics
|May 23, 2026

View abstract on PubMed

Summary
This summary is machine-generated.

This study analyzed nursing notes for myocardial infarction patients, mapping terms to SNOMED CT. The most common data captured involved observing patient condition and vital signs.

Keywords:
Myocardial infarctionNursing recordsSNOMED CT

Related Experiment Videos

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients
03:47

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Published on: July 12, 2024

Area of Science:

  • Clinical Informatics
  • Nursing Informatics
  • Medical Terminology

Background:

  • Unstructured nursing documentation presents challenges in data extraction and analysis.
  • Standardized terminologies are crucial for consistent interpretation of clinical data.
  • Clinical practice guidelines (CPGs) provide a framework for patient care and documentation.

Purpose of the Study:

  • To analyze unstructured nursing documentation for myocardial infarction (MI) patients.
  • To map nursing documentation to SNOMED CT using domains derived from CPGs.
  • To identify frequent concepts and data domains within MI nursing notes.

Main Methods:

  • Utilized 72,234 records from 491 MI patients.
  • Annotated records using 17 domains derived from the Canadian Cardiovascular Society (CCS) and American Heart Association/American College of Cardiology (AHA/ACC) CPGs.
  • Mapped annotated data to SNOMED CT.

    • Main Results:

    • The most frequent concept identified was "Taking patient vital signs (procedure)" (n = 4,432).
    • The most frequent domain was "observation of patient condition" (n = 31,181, representing 43% of records).
    • Demonstrated the feasibility of applying standardized terminologies to unstructured clinical notes.

    Conclusions:

    • Analysis of unstructured nursing documentation using SNOMED CT provides valuable insights.
    • Observation of patient condition is a predominant aspect of nursing care for MI patients.
    • Standardized mapping enhances the utility of nursing notes for research and quality improvement.