May 16, 2024

DOCUMENTATION TOOLS

Here’s a list of 20 documentation tools commonly used in the Nursing and Midwifery profession:

  1. Electronic Health Record (EHR) Systems
  2. Nursing Notes and Reports
  3. Vital Signs Charts
  4. Medication Administration Records (MAR)
  5. Patient Assessment Forms
  6. Nursing Care Plans
  7. Incident Report Forms
  8. Discharge Summaries
  9. Progress Notes
  10. Shift Change Reports
  11. Flow Sheets
  12. Surgical Checklists
  13. Pain Assessment Tools (e.g., Wong-Baker FACES Pain Rating Scale)
  14. Obstetric Record Forms
  15. Fetal Monitoring Charts
  16. Nursing Handover Sheets
  17. Nursing Audit Tools
  18. Informed Consent Forms
  19. Quality Improvement Tools (e.g., Plan-Do-Study-Act cycles)
  20. Patient Education Materials

These tools are essential for maintaining accurate records, ensuring patient safety, and facilitating effective communication among healthcare professionals in the Nursing and Midwifery field.

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