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Data Collection II01:29

Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
Data Collection III01:05

Data Collection III

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

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A Cross-Disciplinary and Multi-Modal Experimental Design for Studying Near-Real-Time Authentic Examination Experiences
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设计和实施电子降落后聚集表格,以加强数据收集.

Simone R Evans-Allison1, Kimberly Pate, Allyson Cochran

  • 1Simone R. Evans-Allison is the Enterprise Director Nursing Excellence - Quality at Advocate Health, Charlotte, NC. Kimberly Pate is the Director of Policy and Professional Development at Atrium Health's Carolinas Medical Center in Charlotte, NC. Allyson Cochran is the Director of the Center for Surgical Outcomes Science at Atrium Health in Charlotte, NC, and an Assistant Professor of Epidemiology and Prevention at Wake Forest University School of Medicine in Winston-Salem, NC.

Nursing management
|December 1, 2025
PubMed
概括

实施电子跌倒后聚集表格 (PFHF) 显著改善了患者跌倒数据的收集. 这种数字工具提高了完成率和员工满意度,有助于防止跌倒的努力.

关键词:
电子数据捕获 电子数据捕获电子落后集结形式 电子落后集结形式在秋天,秋天,秋天下降.防摔 防止跌倒 预防跌倒

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科学领域:

  • 提高医疗保健的质量 改善医疗保健的质量
  • 患者安全研究 患者安全研究
  • 护理信息学 护理信息学

背景情况:

  • 一种基于纸张的落后聚集形式 (PFHF) 是劳动密集型的,完成率低.
  • 现有的PFHF大约有50个问题,阻碍了用于预防跌倒的数据收集.

研究的目的:

  • 为了提高完成后跌落聚集形式 (PFHF) 的完成率.
  • 评估电子PFHF对神经科学部门直接护理护士的影响.

主要方法:

  • 设计并实施了一种电子式的落后聚集形式 (PFHF).
  • 提供了教育,常规反,并利用了诸如力量功能和EHR互操作性等功能.
  • 进行实施前后调查以评估影响.

主要成果:

  • 电子PFHF完成率从11.1%增加到99.6%.
  • 统计学上显著地减少了启动者和验证者的表格填写时间.
  • 在电子实施后减少了员工的丧和担忧.

结论:

  • 电子 PFHF 增强了数据收集,完成率和员工满意度.
  • 在PFHF过程中整合技术支持患者安全和节省成本的举措.
  • 为医疗保健领导者改善数据的可用性,以推动预防跌倒的战略.