1/3/2024 0 Comments In timely manner definition![]() ![]() It is continuous and nursing documentation should reflect this. Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. There is an expectation that shift required documentation is completed within 3 hours of shift start time. National Safety & Quality Health Service Standards. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the Required documentation: minimum documentation required to reflect safe patient care.Real time: nursing documentation entered in a timely manner throughout the shift. ![]() The Hub: presents a timeline view of the orders, events, and requirements for each patient the nurse is assigned to and facilitates efficient documentation.EMR Review: process of working through the EMR activities to collect pertinent patient details.This will ensure consistent clinical communication processes across the RCH. To provide a structured and standardised approach to nursing documentation for inpatients. Documentation provides evidence of care and isĪn important professional and medico legal requirement of nursing practice. Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care. Nursing documentation is essential for clinical communication. ![]()
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