Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...

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

Whose Chart Is It, Anyway? "The purpose of an EHR should be helping the end users (us) to be more efficient in charting and free up time for direct patient care," observed a Medscape reader. However, ...

Nursing documentation is often cited as a factor for nursing burnout, and many organizations are rethinking the approach to the old philosophy of "If it's not documented, it didn't happen." Banner ...

Documentation and assessments are crucial to following patients’ progress. One action research project radically changed processes to improve patient care Abstract Lees L (2010) An action research ...

Speech-to-text software can bring improvements to the quality of nursing documentation but, if benefits to patients are to be maximised, accompanying changes need to be made to how nurses think about, ...