Reference no: EM133793600

Question

The Electronic Health Record (EHR) serves multiple purposes, including tracking patient history, facilitating communication among healthcare providers, and ensuring continuity of care. It provides a digital record of the patient's health information, including assessments, lab results, treatment plans, and notes from different providers. When documenting a physical assessment in the EHR, the nurse must ensure that the information is accurate, concise, and objective. Any findings, whether normal or abnormal, should be clearly noted. It is also important to document the time and date of the assessment and ensure that the documentation complies with institutional policies for accuracy and confidentiality.