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A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation.

Krystle MartinRosemary Ricciardelli
Published in: The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres (2021)
The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.
Keyphrases
  • healthcare
  • mental health
  • electronic health record
  • advance care planning
  • primary care
  • quality improvement
  • mental illness
  • health information
  • case report