background and objectives: standard clinical documentation is an integral part of quality patient care. this study aimed to explore compliance of two iranian teaching hospitals with the clinical documentation standards.   methods: a total of 400 records were surveyed. data were collected using a checklist of standard measures. the checklist comprised 15 items selected from relevant guidelines...

Background and Objectives: Standard clinical documentation is an integral part of quality patient care. This study aimed to explore compliance of two Iranian teaching hospitals with the clinical documentation standards.   Methods: A total of 400 records were surveyed. Data were collected using a checklist of standard measures. The checklist comprised 15 items selected from relevant guidelines...

Imagine a future of integrated clinical information systems that transcend the physical boundaries of clinical units, institutions and community care, providing nurses with comprehensive access to information and knowledge to support the delivery of care to individuals and families. Imagine not having to gather the same information repeatedly, ask the same questions over and over again, or stru...

OBJECTIVE Currently, the processes for harmonizing and extending standards by leveraging the knowledge within local documentation artifacts are not well described. We describe a collaborative project to develop common information models, terminology bindings, and term definitions based on nursing documentation systems, and carry the findings through to the adoption in standards development orga...

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and ...

Social workers' understanding of the relevance of documentation has evolved over time. During the profession's earliest years, social workers viewed documentation primarily as a mechanism to facilitate theory building, research, and teaching. This was followed by social workers' development of detailed and sophisticated documentation standards for clinical and other direct practice settings. Mo...