Documentation: Will we ever get it right?
While the process of documentation seems like it should be simple, in reality it is not. Documentation systems are not always user-friendly; documentation tools are not always appropriate or functional. Processes may be inconsistent with changing needs, or inflexible. The nurse on the hospital floor, at the nursing home or at patients' homes knows it is essential to document; however, conflicting priorities often do not allow adequate time for meaningful, comprehensive chart entries.
The goal of this program is to educate nurses on documentation tools and processes. After reviewing the information, you will be able to:
1. Recognize the pros and cons of differing documentation strategies in use in healthcare.
2. Discuss how to use the electronic medical record as a documentation methodology for support of standard of care.
3. Review your professional documentation and make changes to enhance its effectiveness.
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