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Updated: Oct 26, 2025

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
Published on: July 12, 2024
Opening Up with Open Notes: Writing Notes in the Era of Full Patient Access
Jacqueline Posada1, Hannah Potvin2, Carolyn Cookson3
1George Washington University, Washington, D.C., USA. jposada@mfa.gwu.edu.
No abstract available in PubMed .
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Related Concept Videos
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Legal Guidelines for 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.
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information: