Week 9: Documentation NSE 111 Questions with Complete Answers.

What are the 7 reasons + 1 considerations for documentation - Answer 1. Client Safety 2. Continuity of Care, communication, Clinical Judgement 3. Funding 4. Legal Obligation 5. Population & Clinical Health Insights 6. Quality Improvement 7. Research + 1. Documentation & Violence Key Points of Client Safety (3) - Answer Prevent/minimize unsafe acts Effective communication facilitates effective decision making Act Accordingly Reduce Harm Key Points of Continuity of Care, Communication, Clinical Judgement - Answer Continuity of Care: care is connected and coordinated through experience Communication: communicate clinical information within interprofessional healthcare team for awareness Clinical Judgement: professionally assessing situations before making decisions Key Point of Funding - Answer Documentation records can influence provincial and federal funding Key Points of Legal Obligation (2) - Answer 1. Provides evidence of assessments conducted "If it's not documented, it wasn't done" 2. Can be used as legal evidence/documents e.g. negligent practice, coroner's inquest, violence, child welfare & criminal offences Key Point of Population + Clinical Health Insights - Answer Track data & identify trends across patients/groups/institutions related to transmissions of epidemics/diseases/interventions/complications/effectiveness