Here’s a list of 20 documentation tools commonly used in the Nursing and Midwifery profession:
- Electronic Health Record (EHR) Systems
- Nursing Notes and Reports
- Vital Signs Charts
- Medication Administration Records (MAR)
- Patient Assessment Forms
- Nursing Care Plans
- Incident Report Forms
- Discharge Summaries
- Progress Notes
- Shift Change Reports
- Flow Sheets
- Surgical Checklists
- Pain Assessment Tools (e.g., Wong-Baker FACES Pain Rating Scale)
- Obstetric Record Forms
- Fetal Monitoring Charts
- Nursing Handover Sheets
- Nursing Audit Tools
- Informed Consent Forms
- Quality Improvement Tools (e.g., Plan-Do-Study-Act cycles)
- 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.