Electronic Nursing Documentation forms could be the turning point in providing coordinated care in health care setting. Upon implementing an Electronic Medical Record, Nursing essential forms must be built properly to achieve best results.

1. Nursing Forms Essentials for
EMR
Samir Sawli, PhD
ssawli@yahoo.com

2. Electronic Medical Record
 The EMR is implemented to enhance
medical care provided to patients
 EMR provides the infra structure for
better coordination of care
 EMR decreases error incidents due to
manual input or transcription of data
 Electronic Nursing forms are part of
the EMR
 What are the essential Nursing forms,
and how they better serve the patient
care?

3. Essential Nursing
Documentation Forms
 Any EMR project should start with the
following essential forms
 Nursing Admission Form
Nutrition assessment form
Physical Mobility Assessment Form
Social Assessment Form
Wound and Pressure Ulcer Screening
Form
 Vital Signs Form
 Discharge Form

4. Nursing Forms Behavior
• Dietiens, Physical,
social
• If Screening is
positive, then fire
a consultation
Admission
Form
• Get Notified
• Asses Patient
• Document
Specialized
Consult • Nursing Task List
• Recurring Tests
• Physician Orders
Tasks and
F/U

5. Set Those Forms Right
 Set the Nursing Forms right along with
its behavior to fire specialized consult
 Design Forms with least steps, typing
and clicks
 Design the forms with big fonts and
numbers to avoid errors
 Once possible have the Vital Signs
form capture parameters from the
machines avoiding human error

6. If You Need Support
 Contact us and we will be happy to
give pair of thoughts
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