Documentation Guidelines
Greater Baltimore Medical Center
, General Documentation
Information
• Most nursing documentation is completed on the
computer using Meditech PCS
• Agency nurses will be required to take an 8 hour
Meditech course taught by GBMC before
beginning to work at the hospital
• This class will cover order entry, documentation,
and barcoding medication delivery / using the
electronic medication administration record
, Patient Care System (PCS)
– PCS is the system for documentation that
reflects the nursing process, encourages clear
and concise charting, is legally sound, and
focuses on patient interventions to support
patient outcomes
– All information entered through PCS can be
viewed in the EMR (Enterprise Medical
Record)
, With PCS, you are able to:
• Fill out the Admission Database
• Record vital signs and I&Os
• Document the patient’s Past Medical History
• Document your head-to-toe assessment (using System
Flowsheets)
• Enter nursing notes
• Add Care Plans and record outcomes
• View and print Kardexes and patient reports
• Enter lab, radiology, respiratory, diet, and nursing orders through
order entry
• Document medication administration through the electronic MAR
Greater Baltimore Medical Center
, General Documentation
Information
• Most nursing documentation is completed on the
computer using Meditech PCS
• Agency nurses will be required to take an 8 hour
Meditech course taught by GBMC before
beginning to work at the hospital
• This class will cover order entry, documentation,
and barcoding medication delivery / using the
electronic medication administration record
, Patient Care System (PCS)
– PCS is the system for documentation that
reflects the nursing process, encourages clear
and concise charting, is legally sound, and
focuses on patient interventions to support
patient outcomes
– All information entered through PCS can be
viewed in the EMR (Enterprise Medical
Record)
, With PCS, you are able to:
• Fill out the Admission Database
• Record vital signs and I&Os
• Document the patient’s Past Medical History
• Document your head-to-toe assessment (using System
Flowsheets)
• Enter nursing notes
• Add Care Plans and record outcomes
• View and print Kardexes and patient reports
• Enter lab, radiology, respiratory, diet, and nursing orders through
order entry
• Document medication administration through the electronic MAR
