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Nursing Documentation in the Age of the Electronic Health Record
Pages 12 (3012 words)
Nursing Documentation in the Age of the Electronic Health Record Name Institution Nursing Documentation in the Age of the Electronic Health Record Introduction Health care providers and administrators view record keeping as a critical element that promotes safety, quality, compliance and continuity of service.
Deficiencies in nursing recording have forced the stakeholders to implement interventions aimed at improving healthcare documentation. Healthcare providers need to determine the best approaches for incorporating the elements of nursing into Electronic Health Records. Electronic documentation ensures long-term preservation and storage of records, which promotes evidence-based nursing care (Busch, 2008). Capturing nursing’s independent contributions to patient care requires proper comprehension and application of standardized terminologies that reflect the uniqueness of the healthcare systems. Correct use of standardized terminologies benefits the nursing profession through enhancing communication among the nursing stakeholders, increasing visibility of nursing interventions and facilitating assessment of nursing competency. The Focus of Documentation of Patient Care Information recording is a critical part of medical endeavor. Busch (2008) maintains that medical care requires continuous flow of information before and after each task to maintain continuity of care. The tasks in the medical care are interdependent and build on one another to achieve the goals of nursing practice. Nurses have the responsibility of managing and implementing the plans of the medical team for the patient through recording the progress towards the outcomes. ...
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