Key Elements in Nursing Documentation [INFOGRAPHIC]

Maintaining accurate and timely nursing records is essential for communication among all members of the patient’s healthcare team and to support the delivery of safe, appropriate and continuous care. Nurses are often accountable for creating the patient chart and updating all information from vital signs or emergencies the patient experiences during the hospital stay. To get clear, concise and comprehensive patient charts, it is critical for the nursing documentation to include all the essential components with regards to professional nursing standards. Nursing transcription services provided by experienced companies ensure accurate and timely electronic health record (EHR) documentation. The American Nursing Association (ANA) has set down primary guidelines that serve as the gold standard for the basis of nursing documentation. The ANA recommends that all entries in the medical record must be legible/readable and that standardized terminology should be used to describe the planning, delivery, and evaluation of nursing care.

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Nursing Documentation

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.