NUR 320 - Documentation and
Reporting (correctly answered)
Problem Oriented Advantages
•common problem list that includes input from all disciplines which helps to facilitate
communication among the healthcare members.
•It is easy to monitor the client's progress
•Each discipline has ready access to the findings of the other members of the health team.
- requires a coo- requires a cooperative spirit among health providers as well as diligence in
maintaining a current database and problem list.perative spirit among health providers as well
as diligence in maintaining a current database and problem list.
What is the most important purpose of Documentation?
Assure high quality patient care
Purpose of Patient Records/Documentation
•Communication
•Diagnostic and therapeutic orders
•Care planning
•Quality process and performance improvement
, •Research; decision analysis
•Education
•Credentialing, regulation, and legislation
•Reimbursement
•Legal and historical documentation
Different methods of Reporting Care
•ISBARR
•Change-of-Shift/Hand-off Reports
•Telephone/Telemedicine Reports
•Transfer and Discharge Reports
•Reports to Family Members and Significant Others
•Incident Reports
Characteristics for Effective Documentation
•Consistent with professional and agency standards
•Complete
•Accurate
•Concise
•Factual
•Organized and timely
•Legally prudent
•Confidential
Reporting (correctly answered)
Problem Oriented Advantages
•common problem list that includes input from all disciplines which helps to facilitate
communication among the healthcare members.
•It is easy to monitor the client's progress
•Each discipline has ready access to the findings of the other members of the health team.
- requires a coo- requires a cooperative spirit among health providers as well as diligence in
maintaining a current database and problem list.perative spirit among health providers as well
as diligence in maintaining a current database and problem list.
What is the most important purpose of Documentation?
Assure high quality patient care
Purpose of Patient Records/Documentation
•Communication
•Diagnostic and therapeutic orders
•Care planning
•Quality process and performance improvement
, •Research; decision analysis
•Education
•Credentialing, regulation, and legislation
•Reimbursement
•Legal and historical documentation
Different methods of Reporting Care
•ISBARR
•Change-of-Shift/Hand-off Reports
•Telephone/Telemedicine Reports
•Transfer and Discharge Reports
•Reports to Family Members and Significant Others
•Incident Reports
Characteristics for Effective Documentation
•Consistent with professional and agency standards
•Complete
•Accurate
•Concise
•Factual
•Organized and timely
•Legally prudent
•Confidential
