and continuity of care. The three forms of communication central to nurses professional
institution or agency has policies that specify the nurses documentation responsibilities.
The American Nurses Association (ANA) identifies the following characteristics of
concise, and complete; legible/readable (particularly in terms of the resolution and related
qualities of electronic health record [EHR] content displayed on the screens of various
Professional codes of ethics, agency policies, and state and federal privacy legislation
dictate how patient information can be communicated (verbally and in writing), where
and how it can be stored, the appropriate people and entities to whom it may be divulged,
and the purposes for which it may be divulged. Nurses must be familiar with these
guidelines.
Most agencies have specific policies for patient records. Everyone with access to the
record is expected to maintain its confidentiality. Most agencies grant student nurses
access to patient records for education purposes, in which case the student assumes
terminology or name in order to create a clear record for the caregivers who follow.
Patient records serve many purposes. The ANA writes that the most important of these is
communicating within the health care team and providing information for other
activities.
With EHRs, data can be distributed among many caregivers in a standardized format,
allowing them to compare and uniformly evaluate patient progress easily. Besides
compare the progress of groups of patients with similar diagnoses. These results
contribute to research, education, and improved and more efficient nursing practice.
An electronic health information exchange (HIE) allows doctors, nurses, pharmacists,
other health care providers and patients to appropriately access and securely share a
providers.
A source-oriented paper record is one in which each health care group keeps data on its
own separate form. Sections of the record are designated for nurses, physicians,
laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the
rather than around sources of information. With POMRs, all health care professionals
record information on the same forms. The advantages of this type of record are that the
entire health care team works together to identify a master list of patient problems and
management model.
Formats for nursing documentation include the initial nursing assessment, care plan,
patient care summary, critical/collaborative pathways, progress notes, flow sheets and
agency to another, a discharge summary is written that concisely summarizes the reason
for treatment, significant findings, the procedures performed and treatment rendered, the
patients condition on discharge or transfer, and any specific pertinent instructions given
data to others.
The trend is toward a standardized, streamlined shift report system at the bedside, which
care agencies to document the occurrence of anything out of the ordinary that results in or
has the potential to result in harm to a patient, employee, or visitor. These reports are used
for quality improvement and should not be used for disciplinary action against staff
members.
When nurses detect problems they cannot resolve because they are outside the scope of
other professionals.
Nursing informatics is a specialty that integrates nursing science, computer science, and
nursing practice. Nursing informatics facilitates the integration of data, information, and
knowledge to support patients, nurses, and other providers in their decision making in all