Nursing documentation represents the quality of care that we provided. Through complete documentation, the nurse can claim credit for meeting responsibilities inherent in the profession. Documentation is also a vital adjunct to provide patient care as record of patient’s condition from admission till discharge including discharge care plan. It is a legal document and can …show more content…
It provides crucial legal protection as admissible in court; so the patient’s medical record must be documented in an accurate complete, systematic, logical, concise and timely manner.
We must document exactly what we hear, observe, inspect, do or teach. Include as much specific and descriptive information as possible. And always document how the patient responds to care, treatments, and medications as well as his progress toward the desired outcome. Also, include notification to the doctor of changes that have occurred. Document the doctor’s response, new orders that are followed, and the patient’s response. We can organize the notes by using a head-to-toe approach or referring to the care plan and documenting the patient’s progress.
Thus, whatever kind of documentation system is used, the documentation must communicate the patient’s status, the specific care provided, and the response to that care. Documentation must include the following contents:
Subjective data(S)- reason for seeking care or other information the patient or family members tell …show more content…
Discuss any unresolved problems and specify our plan for dealing with the problems after discharge like patient education and discharge plan.
Let’s talking about Electronic health record (EHR), EHR is a digital version of a patient’s paper chart. It’s real-time, patient-centered records that make information available instantly and securely to users. While an EHR does contain the medical and treatment histories of patients, EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.
The EHR system not only collect, transmit, and organize the information, but they also suggest nursing diagnoses and provide standardized patient status and nursing interventions, which we can use for care plans and progress notes. These systems increase the speed of reporting and free the nurse from paperwork. Computerized charting has several advantages, which it makes storing and retrieving information fast and easy. It will decrease the medication error as using scanner to scan the medication, efficiently update information. In addition, data entry can alert nurses to take action, such as reminding nurses the time for serving medication. However,