Abstract
This toolkit/dataset supplement provides the recommended content for a Head to Toe (H2T) nursing assessment that minimizes documentation burden and maximizes discrete data that is available for reuse. The supplement includes guidelines for charting by exception/within defined limits documentation and creating or revising nursing assessment documentation.
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Keyword(s)
Transforming Documentation Evaluation/Assessment tools Documentation burden (15) Documentation Burden, Improvements, Usability Electronic health record Informatics tools