This post continues our series on Documentation for Correctional Nurses with a discussion of electronic health records. The Electronic Health Record Today, many systems are using an electronic health record (EHR). The benefits of an EHR include improved legibility, improved ... Read More about Correctional Nurse Clinical Practice Update: Documentation IV
The Correctional Nurse
Correctional Nurse Clinical Practice Update: Documentation III
In this post, we continue our discussion of documentation with methods of documentation. Methods of Documentation: Narrative Note In narrative documentation, a summary of the care provided is written in paragraph form. The patient’s status should be described in detail, as well as all ... Read More about Correctional Nurse Clinical Practice Update: Documentation III
Correctional Nurse Clinical Practice Update: Documentation IIB
ELEMENTS OF GOOD DOCUMENTATION In our last post, we discussed nine Elements of Good Documentation. This week, we continue our discussion. Document what the patient tells you with exact quotes Using exactly what the patient tells you in quotation marks provides an indication of the ... Read More about Correctional Nurse Clinical Practice Update: Documentation IIB
Correctional Nurse Clinical Practice Update: Documentation IIA
ELEMENTS OF GOOD DOCUMENTATION Write legibly Since the patient’s health record is the main method by which information about the patient is conveyed to all members of the healthcare team, it is vitally important that all notes can be read by all caregivers. Errors may be made if the record ... Read More about Correctional Nurse Clinical Practice Update: Documentation IIA
Correctional Nurse Clinical Practice Update: Documentation I
Documentation is one of the most critical skills nurses perform, regardless of the setting in which they practice. Accurate, detailed charting provides a clinical picture of the patient and a chronological history of their health care. Nursing documentation enables effective continuity of care for ... Read More about Correctional Nurse Clinical Practice Update: Documentation I