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,…

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

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

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…

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

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…

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…

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

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

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

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…

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

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

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…

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…

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…

Despite the evidence that cardiac rehabilitation (CR) reduces the risk of recurrent cardiac events, only a minority of eligible patients are willing…

TBase is an electronic health record (EHR) for kidney transplant recipients (KTR) combining automated data entry of key clinical data (e.g.,…

This research shows a protocol to assess the computational complexity of querying relational and non-relational (NoSQL (not only Structured Query…