Abstract:
Learn the principle elements that must be addressed in electronic documentation.
Nurse Mesics has an assignment of six patients on a busy medical-surgical unit. Because of the patients' acuity levels, Mesics must frequently document in their charts. He feels that he has wasted valuable time walking back and forth between the patients' rooms and the nurses' station to document patient status. He attends a seminar that addresses his concerns. Mesics is aware of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, but isn't sure what role it plays in his everyday nursing practice. He's decided to be openminded and listen to the advantages and disadvantages of electronic versus paper charting and privacy issues.