Electronic Nursing Documentation Forms Essentials

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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.

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Electronic Nursing Documentation Forms Essentials

  1. 1. Nursing Forms Essentials for EMR Samir Sawli, PhD ssawli@yahoo.com
  2. 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. 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. 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. 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. 6. If You Need Support  Contact us and we will be happy to give pair of thoughts  Health Executive Experts  Hexpert.sharepoint.com

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