What is the best way to manage documentation in nursing?

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 can the nursing process be applied to electronic documentation?

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.

Do nurses experience barriers to maintaining accurate documentation?

However many nurses still experience barriers to maintaining accurate and legally prudent documentation. A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisation identified a lack of clear and easy to follow information about the patient’s progress.

What are the documentation and reporting requirements in nursing?

Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse. 1. Source – Oriented Record Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes 2.

What is documentation and reporting in nursing?

Documentation & Reporting in Nursing. Matt Vera, BSN, R.N. Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse.