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NURS 258: Documentation (E1)
Questions and Correct Answers the
Latest Update
documentation (def.)
✓ anything written or printed; record of proof of patient actions or activities
Documentation must....
✓ - be accurate, comprehensive and easily retrievable
✓ - show continuity of care
✓ - track patient outcomes
✓ - reflect current standards of nursing practice
Purpose of documentation:
✓ -Provides a legal, serial record of client's condition, evaluation and re-evaluation
results, course of therapeutic intervention and response to intervention from
referral to discharge
✓ -Serves as an information source for client care, can be used by a covering therapist
in absence of primary therapist
✓ -Enhances communication among healthcare or educational team members
✓ -Provides data for use in intervention, program evaluation, research, education and
reimbursement
Guidelines for Documentation include information that is:
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✓ (1) Factual
✓ (2) Accurate
✓ (3) Complete
✓ (4) Current
✓ (5) Organized
Factual documentation is
✓ descriptive and objective
✓ is free of judgement and personal opinions
✓ creates a clear picture
✓ documents what you see, hear, smell and feel
Documentation is accurate by:
✓ providing exact measures
✓ being brief & concise (only documenting activity that is specific)
✓ using appropriate terminology with approved abbreviations
✓ use of correct spelling (shows a level of competency)
✓ date and signature
A document is COMPLETE when
✓ - you follow facility guidelines/format/standards
✓ - you follow the ANA Standards of Practice/Nursing process
✓ - you record data gathered, actions taken, individuals notified, and results
✓ - you report inappropriate behavior, refusals, complaints, changes in status, dressing,
tubes and devices, medication/treatments
A document is considered CURRENT when
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NURS 258: Documentation (E1)
Questions and Correct Answers the
Latest Update
documentation (def.)
✓ anything written or printed; record of proof of patient actions or activities
Documentation must....
✓ - be accurate, comprehensive and easily retrievable
✓ - show continuity of care
✓ - track patient outcomes
✓ - reflect current standards of nursing practice
Purpose of documentation:
✓ -Provides a legal, serial record of client's condition, evaluation and re-evaluation
results, course of therapeutic intervention and response to intervention from
referral to discharge
✓ -Serves as an information source for client care, can be used by a covering therapist
in absence of primary therapist
✓ -Enhances communication among healthcare or educational team members
✓ -Provides data for use in intervention, program evaluation, research, education and
reimbursement
Guidelines for Documentation include information that is:
Examify | Smart Grades | Latest update
, #Examify | #OnlineExams | #TestPrep | #StudyResources | #AcademicSuccess |
#ExamPreparation | #QuizTime | #LearningTools | #Education | #StudentSupport
✓ (1) Factual
✓ (2) Accurate
✓ (3) Complete
✓ (4) Current
✓ (5) Organized
Factual documentation is
✓ descriptive and objective
✓ is free of judgement and personal opinions
✓ creates a clear picture
✓ documents what you see, hear, smell and feel
Documentation is accurate by:
✓ providing exact measures
✓ being brief & concise (only documenting activity that is specific)
✓ using appropriate terminology with approved abbreviations
✓ use of correct spelling (shows a level of competency)
✓ date and signature
A document is COMPLETE when
✓ - you follow facility guidelines/format/standards
✓ - you follow the ANA Standards of Practice/Nursing process
✓ - you record data gathered, actions taken, individuals notified, and results
✓ - you report inappropriate behavior, refusals, complaints, changes in status, dressing,
tubes and devices, medication/treatments
A document is considered CURRENT when
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