Among the many other things that are expected of nurses is that they will document something as soon as it happens. This is more than a bit unrealistic since RNs have more than one patient, all with conflicting needs often occurring at the same time, but the sooner something is documented the better. And by that I don't mean within the week; within the shift worked is the presumed "deadline". Otherwise, an addendum needs to be added to the chart. How this is done with EMR is beyond me--I left nursing almost 4 years ago, and only worked with a special section of an EMR. I bet it's not easy to do (nor should it be).
I input "nurses AND timely documentation" into PubMed and got quite a bit. Here's one https://www.ncbi.nlm.nih.gov/pubmed/23520685
Hope this helps!
Eleanor Truex BSN, RN, MLIS
Medical Librarian, Lakeshore Region
IRB Coordinator, PSFH
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-----Original Message-----
From: Medical Libraries Discussion List [mailto:[log in to unmask]] On Behalf Of Lee Hover
Sent: Thursday, April 19, 2018 11:42 AM
To: [log in to unmask]
Subject: Re: Search help: "Timely" Documentation
I just did a quick and dirty on Google with "timely documentation nursing"
and came up with a boatload of likely sounding titles. However, I will leave the combing through them to you:-).
HYH.
Lee Hover, D. Med. Hum.
Lacey, WA
-----Original Message-----
From: Medical Libraries Discussion List [mailto:[log in to unmask]] On Behalf Of Fleuriel, Christine
Sent: Wednesday, April 18, 2018 3:25 PM
To: [log in to unmask]
Subject: Search help: "Timely" Documentation
Hello,
I got the request below from one of my nurses. I have searched in PubMed and CINAHL unsuccessfully to find anything that addresses what is considered "timely." I found some citations that addressed the idea that it's a good thing, but not more precisely what it is. And, as the nurse put it, these "soft" concepts are what can get nurses in a pickle in court. I searched Documentation/standards, timely [text], and nurses/nursing. In the "two heads are better than one" department, I am hoping that someone may have a suggestion on how to find something on this topic. Thank you.
Can you help me find some resources or guidelines regarding "timely"
documentation? I have the ANA Principles of Documentation but am looking for something that suggests some guidelines regarding what is "timely" and what is not.
Chris
Christine Fleuriel, MSLIS
Chief, Library Services (142D)
New Mexico VA Health Care System
1501 San Pedro SE
Albuquerque 87108
(505) 265-1711 ext 2248
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