Nursing Documentation Study Guide 100%
VERIFIED CORRECT!
Why do we document
-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
-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
-Care plan
-Nursing kardex/ patient care summary
-Progress, "narrative," notes
-Flowsheets and graphic records
-Meditation administration record (MAR)
, What to document
-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
-Personal opinions
-Judgmental information
-Vague reference to "the doctor"
*Include providers name, time and why they called/ visited
Why don't nurses document well?
-Lack of time
-Insufficient staffing
-Cumbersome charting formats
-Forgot the detail
VERIFIED CORRECT!
Why do we document
-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
-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
-Care plan
-Nursing kardex/ patient care summary
-Progress, "narrative," notes
-Flowsheets and graphic records
-Meditation administration record (MAR)
, What to document
-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
-Personal opinions
-Judgmental information
-Vague reference to "the doctor"
*Include providers name, time and why they called/ visited
Why don't nurses document well?
-Lack of time
-Insufficient staffing
-Cumbersome charting formats
-Forgot the detail
