:

Janie Brown1, Matthew A Albrecht2, Suzanne Kelly3

  • 1Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia; St John of God Midland Public and Private Hospitals, Australia; Western Australian Group for Evidence Informed Healthcare Practice: A JBI Centre of Excellence, Australia.

PubMed
概括

减少产妇护理护士和助产士的文档负担,提高了他们对文档流程的满意度. 简化患者临床文档有效地解决了关键的不满点.

相关概念视频

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.
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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:
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Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
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Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
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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:
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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
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