Nursing: Nursing Documentation in the Digital Age

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About the Course

Every day, nurses face the challenge of caring for complex, acutely ill patients and their families while trying to manage time for documenting the care provided. Over the years, numerous documentation methods have been developed and implemented in a variety of settings to decrease the amount of time required.  Institutions may adopt certain methods for documentation and even modify methods to fit specific needs. Computerized information systems have been steadily integrated into most healthcare facilities giving rise to the electronic health record. Technology has also provided a means to collect data from electronic documentation which can be used to improve patient outcomes. This course discusses how nursing documentation has evolved in the digital age, including the types of documentation and their advantages and disadvantages.

Learning Outcomes:
Upon completion of this course, the learner will be able to:
  • Describe available methods of nursing documentation, including their advantages and disadvantages.
  • Identify general considerations for selecting a documentation system.
  • Describe electronic health records and the evolution of electronic nursing documentation.
  • Discuss the concept of incentive reimbursement in relation to electronic documentation.
  • Indicate major advantages, disadvantages and best practices of using electronic nursing documentation.
  • Discuss security concerns with the use of electronic documentation.

About the Author: 
Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC

Kim Maryniak, PhD, MSN, BN, RNC-NIC, NEA-BC, has 29+ years of nursing experience with medical-surgical, psychiatry, pediatrics, progressive care, and adult and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, manager, and nursing director. Dr. Maryniak graduated with a nursing diploma in 1989 from Foothills Hospital School of Nursing in Calgary, Alberta. She obtained her BSN from Athabasca University, Alberta, in 2000, MSN from the University of Phoenix in 2005, and PhD in nursing from University of Phoenix in 2018.  Dr. Maryniak is certified in neonatal intensive care nursing and as a nurse executive, advanced. She is active in the American Nurses Association, American Organization of Nurse Executives, and Sigma Theta Tau.  Dr. Maryniak has served in various roles including research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, leadership and professional development, infection control, patient throughout, nursing operations, professional practice, and curriculum development.

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