Nursing Documentation Examination
Why do we document - Correct Answer ✔️✔️-Written record of nursing
interactions
-Guide for reimbursement
-Evidence of care in court of law
-Shows use of the nursing process
-Provides data for quality assurance studies
Documentation - Correct Answer ✔️✔️-Written nursing or interdisciplinary
care plans are the framework for documentation
-Charting organized by nursing diagnosis or problem.
-Implementation of each intervention documented on the flow sheet or nursing
notes
-Evaluation statements placed in nurse's notes and indicate progress toward the
stated expected outcomes and goals
Types of documentation - Correct Answer ✔️✔️-Care plan
, -Nursing kardex/ patient care summary
-Progress, "narrative," notes
-Flowsheets and graphic records
-Meditation administration record (MAR)
What to document - Correct Answer ✔️✔️-Admission, transfer, discharge
-New or changed information/ status
-Signs and symptoms
-Patient behavior
-Nursing interventions and treatments
-Medications
-Procedures
-Pateint teaching
-Patient response
-Communication with provider
What not to document - Correct Answer ✔️✔️-Personal opinions
Why do we document - Correct Answer ✔️✔️-Written record of nursing
interactions
-Guide for reimbursement
-Evidence of care in court of law
-Shows use of the nursing process
-Provides data for quality assurance studies
Documentation - Correct Answer ✔️✔️-Written nursing or interdisciplinary
care plans are the framework for documentation
-Charting organized by nursing diagnosis or problem.
-Implementation of each intervention documented on the flow sheet or nursing
notes
-Evaluation statements placed in nurse's notes and indicate progress toward the
stated expected outcomes and goals
Types of documentation - Correct Answer ✔️✔️-Care plan
, -Nursing kardex/ patient care summary
-Progress, "narrative," notes
-Flowsheets and graphic records
-Meditation administration record (MAR)
What to document - Correct Answer ✔️✔️-Admission, transfer, discharge
-New or changed information/ status
-Signs and symptoms
-Patient behavior
-Nursing interventions and treatments
-Medications
-Procedures
-Pateint teaching
-Patient response
-Communication with provider
What not to document - Correct Answer ✔️✔️-Personal opinions
