Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information. Nursing documentation records essential …

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic …

Health records serve various essential purposes in the healthcare system. Here are some key purposes: • Decision Analysis in Record Review: Using …

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These …

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care: Timely …

 Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory …

Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a …

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize …

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's …

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care …

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to …

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or …

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, …

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare …

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for …

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and …

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments …

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This …

A hand-off report, also known as a change-of-shift report, is a crucial nursing process that ensures the smooth transition of patient care …

An Incident or Occurrence Report in a healthcare setting is a crucial document used to record any unexpected occurrence that may or may not have affected …

Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to …

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

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for …

Health Information Technology (HIT) Health Information Technology, commonly called HIT, integrates advanced information systems and technology in …

Nursing Clinical Information System (NCIS) A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to …