What is computerized documentation in nursing?
Computerized clinical documentation systems (CDS) provide for the documentation of patient care using computers. For example, the CDS records the vital signs directly from the cardio-respiratory monitors, while other documentation, such as nursing assessments are entered by the clinician.
What is computerized document?
A computer document is a file created by a software application. While the term “document” originally referred specifically to word processor documents, it is now used to refer to all types of saved files. Therefore, documents may contain text, images, audio, video, and other types of data.
What is the purpose of the nursing documentation module?
The purpose of this module is to provide an overview of nursing documentation, outlining the professional standards, most common documentation errors and legal risks of nursing documentation in the face of evolving technology and reliance on electronic medical records.
Which is the gold standard for nursing documentation?
Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential principles serving as primary guidelines, as outlined in Table 1 (ANA, 2010a). Nurses must also acquire a keen awareness and understanding of their state’s nurse practice act to ensure documentation reflects specific state laws.
Which is an example of skilled nursing documentation?
Skilled Documentation Examples of Nursing Documentation: Left lateral calf wound healing as evidenced by decrease in size and amount of drainage from last week. Wound now 0.2 cm x 0.5 cm. No drainage at this time. Condition improving as evidenced by now able to ambulate entire distance to dining room for meals with no rest periods required.
Which is the first rule of Nursing documentation?
The first rule of documentation for any nurse is to know the governing laws in the state of practice, the policies and procedures of the institution of practice, and the guidelines from applicable specialty organizations. It’s important to note that when State law and institutional policy are in conflict, state law trumps the institution.