Chapter 9
Documentation and Reporting
Introdução à Documentação e Relatórios
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential ...
Finalidade dos Registros de Saúde I
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic ...
Objetivo dos Registros de Saúde II
Health records serve various essential purposes in the healthcare system. Here are some key purposes:
• Decision Analysis in Record Review: Using ...
Diretrizes para Documentação de Enfermagem I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These ...
Diretrizes para Documentação de Enfermagem II
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely ...
Tipos de Registros I: Registros da Unidade e Enfermeiros
Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory ...
Tipos de Registros II: Registros Educacionais e Administrativos
Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a ...
Métodos de Documentação I: Registros Orientados à Fonte
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 ...
Métodos de Documentação II: POMR
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's ...
Métodos de Documentação III: PIE
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care ...
Métodos de Documentação IV: Gráficos de Foco
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to ...
Métodos de Documentação V: CBE
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or ...
Métodos de Documentação VI: Modelo de Gerenciamento de Casos
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, ...
Métodos de Documentação VII: EMR
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare ...
Diretrizes e estratégias para gráficos de computador seguros
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ...
Formatos para Documentação de Enfermagem
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ...
Fluxograma
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments ...
Formulários de resumo de alta
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 ...
Tipos de relatórios I: Relatório prático
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 ...
Tipos de Relatórios II: Relatório de Incidentes ou Ocorrências
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 ...
Tipos de Relatórios III: Relatórios Telefônicos e Verbais
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to ...
Diretrizes legais para documentação
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines ...
Documentação em ambiente de saúde domiciliar e de longo prazo
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for ...
Tecnologia da Informação em Saúde e Sistema de Informação em Saúde
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in ...
Sistema de Informação Clínica de Enfermagem
Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to ...
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