Related Experiment Video
Updated: Oct 2, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
Developing a module for nursing documentation integrated in the electronic patient record
1Institute of Nursing Science, University of Oslo, Norway. ragnhild.helleso@sykepleievit.uio.no
Abstract:
Norway's regional teaching hospitals are working together on a project to develop an interdisciplinary electronic patient record (EPR). This paper presents the results of a project to develop nursing documentation as part of an integrated EPR to improve the quality and continuity of patient care. The project used a consensus process as a working norm. The most important result is that the five hospitals have agreed on a framework for nursing documentation, and on the main components that need to be implemented in the electronic patient record.
Related Concept Videos
Methods of Documentation VII: EMR
Role of Communication in the Nursing Process III: Evaluation and Documentation
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...