NURSING DOCUMENTATION STUDY MATERIAL
100% VERIFIED CORRECT!
Documentation
anything written or printed relating to the patient--fundamental tenant of nursing care!!
Standards for documentation
all patients must have an assessment of physical, psychosocial, environmental, self-care,
knowledge level and discharge planning needs
Documentation must be...
within context of nursing process
Confidential
nurses are legally and ethically obligated to keep all pt info confidential
protection
nurses are responsible for protected records from all unauthorized readers
HIPPA
requires disclosure or requests regarding health info are limited to the minimum necessary
Interdisciplinary communication
-conferences
-reports
, -referrals
-consultations
Purposes of records
-communication
-legal documentation
-reimbursement
-education and research
-auditing and monitoring
Diagnosis Related Group (DRG)
a system used for the basis of establishing reimbursement for healthcare--SUBJECT TO AUDIT
How do I limit liability?
document individualized, goal-directed care based on the nursing process!
DO's for Recording
-record facts
-record legibly black ink
-chart only for yourself
-begin with date, time, and end with signature and title
-correct errors promptly
-keep pw to yourself
-if order questioned, record clarification sought
100% VERIFIED CORRECT!
Documentation
anything written or printed relating to the patient--fundamental tenant of nursing care!!
Standards for documentation
all patients must have an assessment of physical, psychosocial, environmental, self-care,
knowledge level and discharge planning needs
Documentation must be...
within context of nursing process
Confidential
nurses are legally and ethically obligated to keep all pt info confidential
protection
nurses are responsible for protected records from all unauthorized readers
HIPPA
requires disclosure or requests regarding health info are limited to the minimum necessary
Interdisciplinary communication
-conferences
-reports
, -referrals
-consultations
Purposes of records
-communication
-legal documentation
-reimbursement
-education and research
-auditing and monitoring
Diagnosis Related Group (DRG)
a system used for the basis of establishing reimbursement for healthcare--SUBJECT TO AUDIT
How do I limit liability?
document individualized, goal-directed care based on the nursing process!
DO's for Recording
-record facts
-record legibly black ink
-chart only for yourself
-begin with date, time, and end with signature and title
-correct errors promptly
-keep pw to yourself
-if order questioned, record clarification sought
