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The STAR Model is composed of five major stages: knowledge discovery, evidence summary, translation into practice recommendations, integration into practice, and evaluation. The model is one of the most commonly used frameworks that have shaped evidence-based nursing. [2]
The two main types of CDSS are knowledge-based and non-knowledge-based: [1] An example of how a clinician might use a clinical decision support system is a diagnosis decision support system (DDSS). DDSS requests some of the patients' data and, in response, proposes a set of appropriate diagnoses.
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
The evidence underlying this decision was a survey that showed that the Omaha System was used in 96.5% of Minnesota counties. The Omaha System became a member of the Alliance for Nursing Informatics in 2009. It is a reliable nursing documentation tool for outcome and quality of care measurement for clients with mental illness. [11]
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
Knowledge retention projects are usually introduced in three stages: decision making, planning and implementation. There are differences among researchers on the terms of the stages. For example, Dalkir talks about knowledge capture, sharing and acquisition and Doan et al. introduces initiation, implementation and evaluation.
Health information technology (HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, health data, and knowledge for communication and decision making". [8]