Standardizing electronic nursing documentation.
While nursing moves toward evidence-based practice (EBP), standardization becomes part of the discussion, especially standardization of documentation. Appropriate and clear documentation can increase communication between care providers and improve patient safety.1 Although nursing care standards are readily available, there are far fewer standards for the documentation of that care. This relative gap has led to a wide range of documentation, with little standardization of paper forms or data elements collected.
Nursing Informatics, Baptist Health South Florida, Barry University, Miami Shores, FL, USA.
Melissa
M
Barthold
D055318:Evidence-Based Nursing; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009737:Nursing Records / Q000592:standards*