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 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 ...

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

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 ...

Professor and Associate Dean for Technology and Innovation, and senior scientist at the UAB Informatics Institute, Jacqueline Moss, PhD, RN, FAAN, first became interested in informatics as she ...

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 ...

The nursing profession is changing – in large part fueled by information technology that can help nurses meet a growing list of challenges, said Summer Blackerby, RN, chief nursing information officer ...

While acknowledging the limitations in this study, post-operative nursing documentation appears to have complex and multiple communication, quality, risk and legal implications. Maltese nurses need ...