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 efficiency, and improved availability of patient information to all staff. The clinical decision support included in most EHRs today allows…
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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 treatments and nursing interventions performed and the patient’s response to those interventions. Narrative notes may often…
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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 patient’s mental status and their ability to comprehend what is going on, and it is…
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