75Health EHR Software guarantees accurate and comprehensive medical notes that are stored on the cloud for easy access.
A nursing note is the medical note made by a nurse into a medical record. It provides a clear and accurate reflection of the care provided, nursing assessments, changes in the patient's conditions, and all relevant information that support the clinical team in delivering the best care.
Accurate and comprehensive nursing notes prove vital for arriving at perfect decisions regarding patient care. Nursing notes must are required to offer accurate and clear picture of the patient who is under the healthcare team's care. According to state, federal, and institutional regulations, nursing notes are required to follow broad guidelines for determining whether or not the nurse's action has been prudent and reasonable.
What Information are stored in the Nursing Note
Nursing notes have to follow the guidelines given below:
- Interventions initiated as well as patient's response must always be included when any acute abnormality found in evaluation is being documented
- Any body system abnormality must be always elaborated while documenting, in each assessment
- Patients baseline mental status must be documented
- Whether an assessment was audible, visual, and / or tactile must always be included
- Mismatched subjective and objective assessment findings must be reconciled
- Patients must always be assessed at the time of transfer or discharge
- Quantifiable data must be used with descriptions.
Nursing notes serve several purposes from evaluation of proper medical care to medical malpractice litigation. Hence, it requires that nurses enter nursing notes while keeping in mind the various related audiences as given below:
- The healthcare team
- Attorneys, Jury, and other legal professionals
- The nurse
How Does the Electronic Health Record (EHR) help?
An EHR is designed for ensuring that nursing notes are accurate and complete. By adopting good EHR Systems or Software, nurses will be alerted about any incomplete, missing, or inaccurate nursing notes.
EHR warrants that nursing notes are being stored in an easy-to-access location and that they are never lost. Through EHR use, medical professionals will be able to ensure that they get all the necessary information required for providing the most optimal care possible to patients. Patients may ensure that they have access to all the nursing notes related to their care.