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EMR Guide for the Patients Medical Home 2023 Update This document has not been updated since originally published. The principles remain valid, but some important changes are: 1) AMA Accelerating
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Principles for nursing documentation are guidelines that ensure accurate, consistent, and comprehensive record-keeping of patient care to promote clear communication and quality care.
Nurses and other healthcare professionals involved in patient care and documentation are required to adhere to the principles for nursing documentation.
To fill out principles for nursing documentation, healthcare professionals must provide clear and concise entries that include patient information, observations, assessments, and care provided, using standardized formats and terminologies.
The purpose of principles for nursing documentation is to ensure that patient care is accurately recorded for legal, ethical, and quality assurance purposes, facilitating effective communication among healthcare team members.
Information that must be reported includes patient demographics, medical history, assessments, care interventions, patient responses, and any changes in the patient’s condition.
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