Nursing Documentation Study Guide 100%
VERIFIED CORRECT!
Documentation
Anything written or printed relating to the patient.
It reflects the quality and accountability of care provided.
Joint commission specifies guidelines for documentation.
If you didnt document..you didn't do it!
Standards
Institutional standards/policies often dictate frequency of documentation. Must be within the
context of the nursing process. Head to toe assessment usually is required to be documented
with 12 hrs of admission. Documentation must conform to standards of National Committee for
Quality Assurance (NCQA) and The Joint Commission(TJC) to maintain institutional
accreditation.
Confidentiality
Nurses are legally and ethically obligated to keep all pt info confidential. They are responsible
for protecting records am from all unauthorized readers. HIPAA requires that disclosure or
requests regarding health info are limited to minimum necessary
Potential breeches in confidentiality
Displaying info on a public screen
Sharing printers among units with differing functions
, Sending confidential emails via public networks
Discarding copies of pt info in trash
Holding conversations that can be overheard
Sending confidential messages overheard on pages
Faxing confidential info to unauthorized persons
Interdisciplinary communication
Effective communication among members of health care team is required for pt care. Two
approaches to this: a patients record or chart and reports among caregivers. Includes
conferences, reports, referrals, consultations.
Patient record
Confidential, permanent legal documentation of info relevant to their health care. Available to
all members of their health care team. Contains:
Pt identification and demographic data
Informed consent for tx and procedures
Admission data
Nursing dx or problems and nursing or interdisciplinary care
Record of nursing care tx and evaluation
Medical hx
Medical dx
Therapeutic orders
Medical and health discipline progress note
VERIFIED CORRECT!
Documentation
Anything written or printed relating to the patient.
It reflects the quality and accountability of care provided.
Joint commission specifies guidelines for documentation.
If you didnt document..you didn't do it!
Standards
Institutional standards/policies often dictate frequency of documentation. Must be within the
context of the nursing process. Head to toe assessment usually is required to be documented
with 12 hrs of admission. Documentation must conform to standards of National Committee for
Quality Assurance (NCQA) and The Joint Commission(TJC) to maintain institutional
accreditation.
Confidentiality
Nurses are legally and ethically obligated to keep all pt info confidential. They are responsible
for protecting records am from all unauthorized readers. HIPAA requires that disclosure or
requests regarding health info are limited to minimum necessary
Potential breeches in confidentiality
Displaying info on a public screen
Sharing printers among units with differing functions
, Sending confidential emails via public networks
Discarding copies of pt info in trash
Holding conversations that can be overheard
Sending confidential messages overheard on pages
Faxing confidential info to unauthorized persons
Interdisciplinary communication
Effective communication among members of health care team is required for pt care. Two
approaches to this: a patients record or chart and reports among caregivers. Includes
conferences, reports, referrals, consultations.
Patient record
Confidential, permanent legal documentation of info relevant to their health care. Available to
all members of their health care team. Contains:
Pt identification and demographic data
Informed consent for tx and procedures
Admission data
Nursing dx or problems and nursing or interdisciplinary care
Record of nursing care tx and evaluation
Medical hx
Medical dx
Therapeutic orders
Medical and health discipline progress note
