Nursing Documentation Articles

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Issues in nursing documentation and recordkeeping

1 hours ago Pubmed.ncbi.nlm.nih.gov Show details

14-01-2003The quality of nursing documentation has consistently been found to be failing to meet recommended standards. This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses from achieving good documentation standards. This article will

Publish Year: 2011
Author: Antony Prideaux

Category: Legal importance of nursing documentationShow more

Nursing care activities based on documentation BMC

8 hours ago Bmcnurs.biomedcentral.com Show details

912-019-0352Nurses engage in various activities from the time of a patient’s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

Publish Year: 2019
Author: Mira Asmirajanti, Achir Yani S. Hamid, Rr. Tutik Sri Hariyati
Estimated Reading Time: 9 mins

Category: Challenges to good nursing documentationShow more

Standardized Nursing Documentation Supports Evidence …

1 hours ago Pubmed.ncbi.nlm.nih.gov Show details

Nursing documentation is crucial to high quality, effective and safe nursing care. According to earlier studies nursing documentation practices vary and nursing classifications used in electronic patient records (EPR) are not yet standardized internationally nor nationally. A unified national model …

Publish Year: 2016
Author: Minna Mykkänen, Merja Miettinen, Kaija Saranto

Category: Legal documentation standards in nursingShow more

The legalities of nursing documentation : Nursing2021

9 hours ago Journals.lww.com Show details

The nursing process requires assessment, diagnosis (nursing), planning, implementation, and evaluation. 2 This process must be reflected in the documentation of interactions with the patient during care. Many facilities have streamlined this critical thinking process with acronyms such as PIE (Problem-Intervention-Evaluation), which provide a

Category: Nursing documentation practice worksheetsShow more

Nursing documentation practice and associated factors

2 hours ago Bmcresnotes.biomedcentral.com Show details

104-019-4661Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [].Nursing documentation is the principal clinical information source to meet legal and professional requirements [].It is a vital component of safe, ethical and effective nursing practice whether done …

Publish Year: 2019
Author: Hagos Tasew, Teklewoini Mariye, Girmay Teklay
Estimated Reading Time: 11 mins

Category: Electronic nursing documentation standardsShow more

Importance And Implementation Of Nursing Documentation

3 hours ago Eujournal.org Show details

Nursing documentation has been defined as the record of nursing care that is planned and given to individual patients and clients by qualified nurses or by other caregivers under the direction of a qualified nurse (Urquhart et al. 2009). Nursing documentation is an attempt to present the

Category: Nursing documentation examplesShow more

ANA’s Principles for Nursing Documentation

5 hours ago Nursingworld.org Show details

nursing documentation that is used throughout an organization. ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings. American Nurses Association

File Size: 241KB
Page Count: 33

Category: Nursing documentation guidelinesShow more

Nursing record systems: effects on nursing practice and

3 hours ago Ncbi.nlm.nih.gov Show details

Mahler C, Ammenwerth E, Wagner A, Tautz A, Happek T, Hoppe B, et al. Effects of a computer‐based nursing documentation system on the quality of nursing documentation. Journal of Medical Systems 2007; 31:274‐82. [Google Scholar] Bosman RJ, Rood E, Oudemans‐Van Straaten H, Spoel JI, Wester JPJ, Zandstra DF.

Publish Year: 2018
Author: Christine Urquhart, Rosemary Currell, Maria J Grant, Nicholas R Hardiker

Category: Poor nursing documentationShow more

Stay out of court with proper documentation : Nursing2021

4 hours ago Journals.lww.com Show details

The expert will look at the nursing documentation for clues and evidence that the care rendered wasn't consistent with appropriate nursing care in order to form an expert opinion. If the plaintiff proves all four elements, damages will likely be awarded to compensate the plaintiff for economic losses (medical costs, lost wages) and noneconomic

Category: Web DocumentShow more

Charting and Documentation Chronicle of Nursing. …

2 hours ago Asrn.org Show details

Always follow the facility's policy with regard to charting and documentation. Resources: Guido, G. (2001). Legal and ethical issues in nursing. Upper Saddle River, NJ:Prentice-Hall, Inc. Schiavenato, M. (2004). Quick-E charting: Documentation and medical terminology - Clinical nursing reference. Orlando, FL: Bandido Books.

Category: Web DocumentShow more

Fundamental charting principles for nurses NSO

6 hours ago Nso.com Show details

Documentation is a core nursing competency, which helps to ensure that patients receive appropriate, high-quality health care services. While it may be difficult to find time for nurses to document patient care in addition to their other clinical and administrative responsibilities, one of the nurse’s primary professional responsibilities is

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Why Is Documentation Important in Nursing Profession

4 hours ago Educationviews.org Show details

Nursing documentation can be a strong evidence to a lawsuit that will help in solving the case. All nursing interventions listed in the notes are considered to be accurate and reliable. If a specific action was not written in the documentation, this particular intervention is …

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Do's and don'ts of nursing documentation. NSO

Just Now Nso.com Show details

Sloppy documentation practices can be used against a nurse in a malpractice lawsuit. Here are some good tips to follow when charting: Do's . Before entering anything, ensure the correct chart is being used ; Ensure all documentation reflects the nursing process …

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Quantifying and Visualizing Nursing Flowsheet

3 hours ago Ncbi.nlm.nih.gov Show details

Several studies have described the problem of documentation burden, including time-motion studies, reporting that nurses spend between 19% to 35% of nursing practice time documenting care. 5-7 However, there are inconsistent findings related to the impact of EHRs on time spent charting. 8,9 Time motion studies provide deep understanding of

Publish Year: 2018
Author: Sarah A. Collins, Brittany Couture, Min-Jeoung Kang, Min-Jeoung Kang, Patricia C. Dykes, Patricia C....

Category: Web DocumentShow more

Nurse documentation contributes to lawsuit dismissal

1 hours ago Nurse.com Show details

Today, professional nurses are vital partners with other healthcare professionals, and nursing documentation is an essential part of comprehensive patient care. Although documentation has always been an important part of nursing practice, the increasingly complex healthcare environment, litigious society and the diversity of settings in which

Category: Web DocumentShow more

Improving Nursing Documentation and Reducing Risk

2 hours ago Hcmarketplace.com Show details

Nursing Documentation and Reducing Risk Patricia A. Duclos-Miller, MSN, RN, NE-BC Improving Nursing Documentation and Reducing Risk Patricia A. Duclos-Miller, MSN, RN, NE-BC In the age of electronic health records and value-based purchasing, accurate and complete nursing documentation is crucial. Proper

Category: Web DocumentShow more

Using Electronic Software for Nursing Documentation in

3 hours ago Ncbi.nlm.nih.gov Show details

Introduction. Nursing documentation is the process of maintaining record of nursing interventions that are planned and implemented for every patient by nurses (Broderick & Coffey, 2013; Mykkanen et al., 2016).Its fundamental purpose is to manifest evidence of nursing care, communicate medical information effectively with others in the healthcare team, meet continuity of care, improve …

Author: Kamran Ranjbar, Raheleh Sabetsarvestani, Hossein Oghlaee, Parisa Sabet Sarvestani, Azizallah Dehghan...
Publish Year: 2021

Category: Web DocumentShow more

Examples & Functions of Nursing Documentation

8 hours ago Medicalandhealthcare.com Show details

According to an article by Nikki Campos, “The Legalities of Nursing Documentation,” published on Lippincott’s online NursingCenter.com, “the objective of any state’s nursing practice, act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the

Category: Web DocumentShow more

Unsafe nursing documentation: A qualitative content

7 hours ago Journals.sagepub.com Show details

In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, …

Publish Year: 2020
Author: Ali Tajabadi, Fazlollah Ahmadi, Afsaneh Sadooghi Asl, Mojtaba Vaismoradi

Category: Web DocumentShow more

Nursing Documentation Nursing On Point

9 hours ago Nursingonpoint.com Show details

Documentation is the record of your nursing care. Documentation is the primary way that we, as RN’s, demonstrate what we did, for whom, when, and with what effects. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes.

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20 Dos and Don'ts for Documentation Ausmed

8 hours ago Ausmed.com Show details

20 Documentation Dos and Don’ts. Nursing documentation includes any and all forms of documentation by a nurse or midwife recorded in a professional capacity and in relation to the provision of nursing care. This video collection explains concisely what nursing documentation is and presents 20 fundamental principles of sound nursing documentation.

Estimated Reading Time: 4 mins

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What is the problem with nursing documentation

7 hours ago Sciencedirect.com Show details

Nursing documentation reflects the quality in patient care. It promotes effective communication between caregivers. However, although its significance has been discussed in numerous articles, nursing documentation remains problematic in Indonesia.

Publish Year: 2018
Author: Hajjul Kamil, R. Rachmah, Elly Wardani

Category: Web DocumentShow more

(PDF) Improving the quality of nursing documentation: An

4 hours ago Researchgate.net Show details

Nursing documentation is the process of recording 1,2 and keeping evidence to have an account of what happened and when it happened. 1,3,4 It is an integral, vital, and important part of

Estimated Reading Time: 6 mins

Category: Web DocumentShow more

Documentation: Accurate and Legal RN.org®

8 hours ago Rn.org Show details

clients and have standards for documentation. Nursing process There are many different approaches to charting, but nurses should remember to always follow the nursing process because that’s the basis for documentation, regardless of the format in which documentation is done: • Assessment: Review of history, physical assessment, and interview.

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‘Gaps, mishaps and overlaps’. Nursing documentation: How

8 hours ago Journals.sagepub.com Show details

Munyisia, E, Yu, P, Hailey, D (2012) The impact of an electronic nursing documentation system on efficiency of documentation by caregivers in a residential aged care facility. Journal of Clinical Nursing 21(19/20): 2940 – 2948 .

Publish Year: 2016
Author: Liz Charalambous, Sarah Goldberg
Estimated Reading Time: 7 mins

Category: Web DocumentShow more

Importance of Documentation in Nursing: The Do's and Don

2 hours ago Careerguts.com Show details

This is because documentation is evidence that the patient received proper care. Documentation allows you to demonstrate how you provided the patient with a standard of care that meets the institutional and board standards in the state where you practice. This article highlights the dos and dont’s of nursing documentation.

Estimated Reading Time: 7 mins

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Relationship Between Nursing Documentation and Patients

4 hours ago Aacnjournals.org Show details

Data-mining methods were used to analyze electronic nursing documentation from a 15-month period at a large, urban academic medical center. Mortality rates and the frequency of vital sign measurements (beyond required) and optional nursing comment documentation were analyzed for a random set of patients and patients who experienced a cardiac

Publish Year: 2013
Author: Sarah A. Collins, Kenrick Cato, David Albers, Karen Scott, Peter D. Stetson, Suzanne Bakken, David K...

Category: Web DocumentShow more

A systematic literature review of accuracy in nursing care

1 hours ago Collegianjournal.com Show details

The current trends in nursing documentation are narrative style nursing documentation, using standardised care plans with the recent transition of many healthcare organisations to electronic health care records (Thoroddsen …

Publish Year: 2017
Author: Linden Johnson, Karen-leigh Edward, Karen-leigh Edward, Jo-Ann Giandinoto

Category: Literature ReviewShow more

(PDF) Nursing documentation: Frameworks and barriers

6 hours ago Researchgate.net Show details

This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records.

Estimated Reading Time: 5 mins

Category: Web DocumentShow more

Frontiers Patient Safety Through Nursing Documentation

7 hours ago Frontiersin.org Show details

This study has identified few articles focusing on the connection between patient safety and nursing documentation practices at home health nursing services or nursing homes. Additionally, there is a need observed for additional research projects that focus on students’ experiences regarding the practice of patient documentation and the use

Author: Jorunn Bjerkan, Victor Valderaune, Rose Mari Olsen
Publish Year: 2021

Category: Web DocumentShow more

Validation of nursing documentation regarding inhospital

9 hours ago Bmcnurs.biomedcentral.com Show details

912-021-0057Background In-hospital fall incidents are common and sensitive to nursing care. It is therefore important to have easy access to valid patient data to evaluate and follow-up nursing care. The aim of the study was to validate the nursing documentation, using a specific term in the registered nurses´ (RNs´) discharge note, regarding inpatient falls according to the outcome of a digitalized

Author: Karolina Krakau, Helene Andersson, Åsa Franzén Dahlin, Louise Egberg, Eila Sterner, Eila Sterner, Ma...
Publish Year: 2021

Category: Web DocumentShow more

Documentation by the Nurse Texas Health and Human

5 hours ago Hhs.texas.gov Show details

Proper Documentation Example #1: 03/21/14 0800 Mrs. GH alert, awake, and oriented to person and situation but is confused as to time and place. She is able to state her name and that she is in the nursing home but states that it is afternoon and that it is 1990.

Category: TexasShow more

ED nursing documentation: Read, react, and reconcile

3 hours ago Reliasmedia.com Show details

The purpose of this article is to examine ED nursing documentation and the emergency physician's interaction with it. Cases will illustrate the critical value of ED nursing documentation and underscore the need for the emergency physician to review, acknowledge, be responsive to, and resolve any discrepancies in real time.

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Challenges in Nursing Informatics RN Journal

5 hours ago Rn-journal.com Show details

Nursing documentation is a dynamic and complex process. As an educator of nursing students, the writer is concerned not only with the present gaps in nursing documentation to the electronic record, but with abilities of nursing students to learn the skill. Because institutions providing clinical experience to students utilize varying charting

Category: JournalShow more

Quality of nursing documentation: Paper‐based health

8 hours ago Onlinelibrary.wiley.com Show details

Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organised within the system known as the electronic health records. Nursing documentation must be completed at the highest standards, to ensure the safety and quality of healthcare services.

Publish Year: 2018
Author: Laila Akhu‐Zaheya, Rowaida Al‐Maaitah, Salam Hasan Bany Hani

Category: Web DocumentShow more

Nursing Documentation in the Electronic Age Case Study

2 hours ago Nursingexperts.org Show details

Viewpoints of experts are analyzed and well informed Incorporates sources of evidence from at least two, Nursing Documentation in the Electronic Age Case Study. discipline-specific, peerreviewed journal article Incorporates at least two sources of evidence from peerreviewed journals but fails to make connection to case study clear Does not

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Improving the Quality of Electronic Documentation in

1 hours ago Scholarworks.waldenu.edu Show details

Allied Health were searched for articles addressing electronic nursing documentation practices. The Cochrane systematic review methodology was used to analyze the articles. Articles were excluded if published before 2001 or not in the English language. The search revealed 860 articles of which 35 were included in the final review. Most studies

Author: Brent Alan Stevens
Publish Year: 2017

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Nursing Documentation in the Age of the Electronic Health

1 hours ago Studentshare.org Show details

The paper "Nursing Documentation in the Age of the Electronic Health Record" states that documentation in nursing focuses on ensuring a continuous flow of StudentShare Our website is a unique platform where students can share their papers in a …

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Importance of Documentation Care in Nursing

Just Now Nursinganswers.net Show details

The nursing literature suggests that the completion of nursing documentation has been one of the most important functions of nurses, even from the beginning of the profesion in the time in the time of Florence Nightingale (Cheevakasemsook et al, 2006). Documentation of nursing care is an important source of reference and communication between

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Nursing documentation: Frameworks and barriers

2 hours ago Tandfonline.com Show details

The quality of nursing documentation is an important issue for nurses both nationally and internationally. Nursing documentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions, while providing written evidence of the progress of the patient.

Publish Year: 2012
Author: Wendy Blair, Barbara Smith

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Importance of Documentation Care in Nursing

6 hours ago Ukessays.com Show details

Journal of Advanced Nursing 39 (5) 450-458. Austin, S. (2006) Ladies and Gentlemen of the Jury, I present: the nursing documentation. Nursing 2006 36 (1) 56-65. Bjorvell, C., Wredling, R. and Thorell-Ekstrand, I. (2003) Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses.

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Documentation Bad Habits: Shortcuts in Electronic Records

9 hours ago Library.ahima.org Show details

Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk. by Chris Dimick. Electronic documentation habits such as copy and paste save valuable time, but they can ruin the record. As the patient’s health worsened, a hospital stay of days turned to weeks. But through the various tests and physician visits, the progress notes

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Frequently Asked Questions

What is the purpose of documentation in nursing?

Introduction. Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.

What are the best practices for nursing documentation?

The Best Practices in Nursing Documentation. Documentation is mandatory for nurses, as the medical records they produce are considered legal materials. These professionals should maintain accurate information, including a chronology of events that features the date, time and nurse's full signature after services were provided.

Why is good nursing documentation so important?

Good documentation is an important part of improving both patient care and nursing practice. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. To find out more about the specific documentation standards where you practice, contact your state board of nursing.

What is the definition of documentation in nursing?

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process.

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