Related Experiment Videos

Nursing documentation practice on 153 hospital wards in Sweden as described by nurses

M Ehnfors

    Scandinavian Journal of Caring Sciences
    |January 1, 1993
    PubMed

    Related Concept Videos

    Role of Communication in the Nursing Process III: Evaluation and Documentation01:08

    Role of Communication in the Nursing Process III: Evaluation and Documentation

    A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
    Introduction to Documentation and Reporting01:20

    Introduction to Documentation and Reporting

    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 and precise...
    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.
    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.
    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...
    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