In Epic, there are often many different ways to document the same item – and some ways are better than others.
A dedicated group of clinical nurse educators, with support from the Nursing Informatics team, are developing a set of PeC Documentation Best Practices to help facilitate and standardize nursing documentation.
Electronic nursing documentation has the benefit of making the output of our patient care assessments and interventions more visible in the patient’s record. Standardization of nursing documentation in the electronic health record (EHR) has the added benefit of making the important information nurses document easier for all clinicians to locate and consume.
Additionally, it allows nursing as a discipline to evaluate the impact of nursing care interventions on patient outcomes and potentially generate new nursing knowledge.
These best practices can be found in the Clinical Practice Manual under the chapter titled “Documentation Best Practices.” Recent additions to this folder include: Intake and Output, Nursing Notes, Drains, Ostomies, Urine, and Stool.
If you have any questions regarding the content of the documents please feel free to contact the Nursing Informatics Team at firstname.lastname@example.org or your unit based clinical nurse educator.