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Nurse documentation and the electronic health record

    https://www.myamericannurse.com/documentation-electronic-health-record/
    Over a period of 3 months, we retrospectively audited patient records from the medical-surgical area for baseline nursing documentation; data elements were analyzed for care decisions and patient safety. The initial work helped identify a number of design gaps, including fields that nurses weren’t … See more

Electronic Health Records | CMS

    https://www.cms.gov/Medicare/E-Health/EHealthRecords
    An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the …

Changes in Efficiency and Quality of Nursing Electronic …

    https://journals.lww.com/cinjournal/Fulltext/2019/05000/Changes_in_Efficiency_and_Quality_of_Nursing.5.aspx
    Electronic health record (EHR) nursing documentation offers a method to record the patient's health status, individual needs, and responses to care, and to support clinical …

Essential Nurse Documentation: Studying EHR Burden …

    https://digital.ahrq.gov/ahrq-funded-projects/essential-nurse-documentation-studying-ehr-burden-during-covid-19-endburden
    Project Details - Electronic health record (EHR) burden—the negative impact electronic clinical documentation has on medical staff—has been an ongoing issue for …

What Are Some Pros and Cons of Using Electronic …

    https://www.registerednursing.org/articles/pros-cons-using-electronic-charting/
    Nursing care plans and shift notes had to be hand-written, and if an error is made in the documentation, some nurses may remember having to draw a single line …

ANA’s Principles for Nursing Documentation

    https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf
    nursing documentation that is used throughout an organization. ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this …

Electronic nursing documentation interventions to …

    https://pubmed.ncbi.nlm.nih.gov/30387215/
    Aim: To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute …

5 Legal Requirements For Computerized Nursing …

    https://digitalhealth.folio3.com/blog/5-legal-requirements-for-nursing-documentation/
    How to Write Nursing Documentation With Electronic Health Records? The nursing documentation is responsible for supporting patient care and improving …

Documentation Matters Toolkit | CMS

    https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation
    Documentation Matters Toolkit Providers are responsible for documenting each patient encounter completely, accurately, and on time. Because providers rely on documentation to communicate important …

What Is The Impact Of EHR In Nursing Practice? - Folio3 …

    https://digitalhealth.folio3.com/blog/impact-of-ehr-in-nursing-practice/
    An EHR contains up-to-date information on patient assessments, clinical problems, clinical reports and lab results, communications with other health care …



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