What is electronic documentation in nursing?
Electronic documentation includes such skills as electronic data entry and data extraction for preparing care plans, planning patient care and education, and discharge planning; it is rapidly becoming a major practice competency.
What documents should a nurse have?
The nursing record should include assessment, planning, implementation, and evaluation of care. Ensure the record begins with an identification sheet. This contains the patient’s personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.
What is electronic documentation in healthcare?
An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.
What is an EDM system?
An Electronic Document Management System (EDMS) is a collection of technologies that work together to provide a comprehensive solution for managing the creation, capture, indexing, storage, retrieval, and disposition of records and information assets of the organization.
How is nursing documentation aligned with the nursing process?
Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this. Fig 1. Nursing Process At the beginning of each shift, a ‘shift assessment’ is completed as outlined in the Nursing Assessment Guideline.
What are the best frameworks for nursing documentation?
A number of frameworks are currently available to assist with nursing documentation including narrative charting, problem orientated approaches, clinical pathways, and focus notes. However many nurses still experience barriers to maintaining accurate and legally prudent documentation.
How long does it take to complete nursing documentation?
There is an expectation that shift required documentation is completed within 3 hours of shift start time. Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation.
Why is nursing documentation necessary for good clinical communication?
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
