Nursing Documentation Electronic Medical Records

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Nurse documentation and the electronic health record

https://www.myamericannurse.com/documentation-electronic-health-record/

If not used properly, the electronic health record (EHR) can create communication gaps. The nursing process can be applied to electronic documentation to avoid workarounds and close gaps in communication. Effective use the EHR can improve patient safety and care outcomes. Clinical documentation supports pati… See more

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 …

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 …

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 …

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 …

What is an electronic health record (EHR)? | HealthIT.gov

https://www.healthit.gov/faq/what-electronic-health-record-ehr

EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment …

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 Health Record | American Nurses Association

https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/electronic-health-record/

ANA strongly supports efforts to further refine the concept and requirements of the patient-centric EHR, including the creation of standards-based electronic health records and …

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 …

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

https://digitalhealth.folio3.com/blog/impact-of-ehr-in-nursing-practice/

Nursing documentation using EHR is important since complete, timely, and accurate medical record keeping ensures that patients get the right care at the right …

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