Nursing Informatics
Electronic Health Record (EHR) Documentation
The EHR is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.
Core Principles
- Ensure all entries are timed, dated, and signed.
- Use standardized medical terminology and approved abbreviations.
- Maintain data integrity by documenting in real-time.
- Follow facility policy for late entries and corrections.
Nursing Best Practices
- Protect patient privacy via unique user authentication.
- Avoid sharing passwords or leaving terminals unattended.
- Ensure objective, non-judgmental, and factual documentation.
- Utilize point-of-care devices to reduce transcription errors.
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