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Nursing Documentation
 
The system provides two automated methods for nursing documentation:

Electronic Nursing Documentation (END)
An alternative to templates, areas include general assessment, pediatric development, multi-trauma, burns, thrombolytic therapy, nursing diagnosis and more.

  • Provides a methodology that assures consistent, legible, and high quality documentation in all areas of Emergency Nursing - reducing risk.
  • Improves efficiencies by creating a "paperless" environment thereby reducing the need for completing multiple forms - reduces expense.
  • Enhances efficiencies of the nursing staff and increases accessibility to patient records - decreases time spent searching for charts/information.
  • Includes prompts to assure thorough documentation for all areas of assessment and of APC procedures, optimizing billing opportunities.
  • Assists the nursing staff in complying with Standards of Emergency Nurse Practices and JCAHO.
  • An objective and automatic generation of patient acuity based on level of service provided and documented.


Template Nursing Documentation (TND)

  • Complaint specific forms print on demand, eliminating printing and storage costs.
  • Provides nursing diagnosis and plan of care areas for thorough quality documentation.
  • Recommended pain and psychosocial assessment to enhance compliance with JCAHO documentation requirements.
  • Clearly defined areas for documentation of procedures ordered and completed.
  • Optimizes APC coding and associated reimbursement.
  • Additional forms can be customized to meet your hospital's needs.
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