1.Compare the focus of documentation of patient care in an agency with the ways patient care data are used.
2.Define standardized nursing terminologies and the associated concepts.
3.Interpret how electronic documentation using standardized terminologies can inform evidence-based care.
4.Differentiate between the nursing minimum data set and nursing focused terminologies.
Introduction
Health care providers and administrators view record keeping as a critical element that promotes safety quality compliance and continuity of service. Nursing documentation is surrounded by a variety of tensions such as the amount of time spent on preparing documents number of errors in records the need to promote legal accountability and the necessity of ensuring understandability of nursing notes to other disciplines. Deficiencies in nursing recording have forced the stakeholders to implement interventions aimed at improving healthcare documentation. Healthcare providers need to determine the best approaches for incorporating the elements of nursing into Electronic Health Records. Electronic documentation ensures long-term preservation and storage of records which promotes evidence-based nursing care (Busch 2008). Capturing nursings independent contributions to patient care requires proper comprehension and application of standardized terminologies that reflect the uniqueness of the healthcare systems. Correct use of standardized terminologies benefits the nursing profession through enhancing communication among the nursing stakeholders increasing visibility of nursing interventions and facilitating assessment of nursing competency.
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