Keeping accurate documentation and nursing charts of your patients' information is sound business practice for your health care facility, doctor's office or clinic. All health care personnel should be ...

Accurate coding and documentation enable seamless care coordination and continuity for patients. Through comprehensive documentation, primary care providers (PCPs) can capture all relevant patient ...

This Tip of the Week focuses on one of the most essential and sometimes overlooked elements of Behavioral Intervention Team (BIT)/CARE Team work: documentation. In this two-part resource, we will ...

Nursing documentation is a cornerstone of contemporary healthcare, integrating systematic recording of patient observations, interventions, and outcomes with the aim of enhancing effective care ...

Back in the days when computerized documentation was still a pipe dream and we had callouses from so much writing, nurses often grumbled about charting. Here is a familiar observation: "In spite of ...

The importance of record keeping is highlighted in the Nursing and Midwifery Council’s (2018) code of conduct as being integral to each of the professional standards. It is generally accepted that ...

Credit: Getty Images. Providing nursing students with the opportunity to audit nursing charts in a real-world scenario may change their perspective about the charting process. The entire student audit ...

Advocate Health has been aiming to take cognitive and documentation load off its nursing staff by implementing AI and virtual nursing. The Charlotte, N.C.-based health system recently launched Project ...

This week, we are building on our previous discussion of why documentation is essential for BIT/CARE Teams. In this installment, we introduce practical strategies, drawing from industry guidance and ...

"We must remember that the EHR is a tool; it should not dictate how we practice," wrote a Medscape reader. Perhaps it should not, but does it? The fact is, EHRs are far more than a method of entering ...