NSE 13A/B Chapter Notes - Chapter 6: Electronic Health Record, Clinical Decision Support System, Client Confidentiality
18 Dec 2018
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Document Summary
Documentation : nursing action that produces a written account of pertinent ( impt and relevant) data, nursing clinical decision and interventions and pt responses in a health record approx. 21. 5% of nursing practice time dedicated to documentation needs to be accurate and comprehensive as it indicates the quality of care given. * recall that the effectiveness of quality of care is dependent on the ability for hcps to effectively communication with one another purposes of medical records. All impt pt info is entered into the medical records. Facilitates funding and resource management shows how health care agency is using their resources or how their resources are being used. Serve as sources of research data and learning resources for nursing and health care education. Impt in cases of being audited: ie: evaluation of the appropriateness and quality of care provided to pt the shift to electronic documentation.
