Question

Using clinical guidelines and standards of care, identify what data elements should be included in the EHR assessment and evaluation screens if these goals are to be achieved.

Answer 1

Ans) Data elements to be included in the EHR assessment:

- Major components of the electronic health record: Health information, diagnostic test results, an order-entry system, and decision support

-It should be accessible, accurate, timely nursing dcomentation, that is clear, concise, complete, and objective.

- Documentation should be factual and nonjudgemental, with proper spelling and grammar.

- Sequencingof events should be in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation.

- Each entry should include the date, time, and signature with credentials of the person documenting.

- Double documentation should be avoided because legal issues can arise due to conflicting data.