Open Forum

Greetings, 

My Health system recently completed a learning needs assessment, and it was identified that many of our clinical members need help documenting clear and accurate progress notes. I am looking for resources on standardizing the documentation process in our EMR for licensed and unlicensed clinical staff. I would be grateful if anyone has access to or can recommend a guide for standardized chart documentation. Thank you for your support. 

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Carrie Moyer
Clinical Nurse Manager
Tower Health
Denver PA
(610)898-2462
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Good morning Carrie,

You might cast a broader net on this question if you post in the Staff Education forum! I'm interested in this topic as well! Out nurses also struggle with good documentation. I've found that use of smartphrases is really helpful to make sure all necessary information is included in a note.

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Torie Bonnet MSN RN NE-BC
Clinical Nurse Edu Specialist-Ambulatory Care
UNC Health
Raleigh NC

torie.bonnet@unchealth.unc.edu
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