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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11] Cyclic and dynamic
The personal health or care plan is designed to capture the patient's narrative. A common understanding of strategies, goals and evaluation of the outcomes should be established. The documentation should clearly state the responsibilities of each member of the team, including the patient's own role and obligations.
The Journal of Documentation is a double-blind peer-reviewed academic journal covering theories, concepts, models, frameworks, and philosophies in information science. The journal publishes scholarly articles, research reports, and critical reviews. The first editor was Theodore Besterman. [2]
The journal was established as a quarterly journal in 2008 with Kathleen Buckwalter as founding editor-in-chief. [1] She served until 2012, when she was succeeded by Christine R. Kovach. [2] In 2014, the journal increased its publication frequency from four issues per year to six. [3]
The National Institute for Health and Care Research (NIHR) is the British government's major funder of clinical, public health, social care and translational research. [3] With a budget of over £1.2 billion in 2020–21, [4] its mission is to "improve the health and wealth of the nation through research". [5]
The intent of this research is to identify shortfalls in practice and to develop strategies to improve care. Like clinical trials, outcomes research seeks to provide evidence about which interventions work best for which types of patients and under what circumstances. However, the evaluation methodology of outcomes research may include both ...