Nursing documentation is a cornerstone of contemporary healthcare, integrating systematic recording of patient observations, interventions, and outcomes with the aim of enhancing effective care ...

Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...

Whose Chart Is It, Anyway? "The purpose of an EHR should be helping the end users (us) to be more efficient in charting and free up time for direct patient care," observed a Medscape reader. However, ...

As the Cardiovascular (CV) Clinical Nurse Specialist (CNS) at The Miriam Hospital (TMH), it is my responsibility to provide for our heart failure patients. In this capacity I have been a resource to ...

For years I have referred to the State Operations Manual (SOM) Appendix P for guidance on the survey process. But the Centers for Medicare & Medicaid Services recently announced that Appendix P will ...