Electronic Nursing Documentation Standards

As technology continues to advance, changes in the way nurses document the care they give has changed. Nurses are now required to electronically document all procedures, medications and services provided to every patient.

Reasons for Electronic Documentation

• According to a study conducted by the Maryland Nursing Workforce Commission, there were a number of problems with traditional paper documentation of all care given. It was found that documentation was often redundant, and time spent on documentation was taking away a nurse's time for direct patient care. Additionally, nurses found themselves working overtime to complete documentation. As such, electronic documentation was found to be more effective.

Nursing Documentation Role

• According to the College of Registered Nurses of British Columbia, nurses need to document all data in a timely manner. Nursing documentation should include a nursing care plan, patient demographic data, assessment sheets, vitals, patient risk management, patient care flow sheets, pain management and a discharge plan.

Benefits

• By timely and correctly documenting electronic records, information is now readily available around the clock. The information is secure, timely and accurate. Doctors and nurses are able to see what care was given and continue on the correct path, guaranteeing a better patient outcome. Electronic documentation increases clinician workflow and can be accessed anywhere at any time.