As our organization looks at implementing some nurse led visits, my leadership team and nurse informaticist are interested in best practices related to documentation in the EHR. (We use Epic) Specifically, how are you standardizing:
- A nursing focused assessment process and documentation; is a focused assessment performed for each encounter
- Nursing procedure and intervention documentation
- Documentation for escalation of care
Currently, it appears that each of our nurses has a different approach on what they are documenting in a patient encounter so would like to know if you utilize a standardized nurse visit template for documentation to ensure that vital information is in the patient's EMR. Thanks for sharing.
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Laurel More RN, MS, NPD-BC, CPN
Children's Hospital Colorado
Clinical Education Specialist
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