< Back to Core

Chapter 9

文書化と報告

Chapter 9

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 …
This research shows a protocol to assess the computational complexity of querying relational and non-relational (NoSQL (not only Structured Query …
Despite the evidence that cardiac rehabilitation (CR) reduces the risk of recurrent cardiac events, only a minority of eligible patients are willing to …
TBase is an electronic health record (EHR) for kidney transplant recipients (KTR) combining automated data entry of key clinical data (e.g., laboratory …