NURS 258 Documentation (E1)
Test With Solution
Documentation (def.) - ANSWER anything written or printed; record of proof
of patient actions or activities
Documentation must.... - ANSWER - be accurate, comprehensive and easily
retrievable
- show continuity of care
- track patient outcomes
- reflect current standards of nursing practice
Purpose of documentation: - ANSWER -Provides a legal, serial record of
client's condition, evaluation and re-evaluation results, course of therapeutic
intervention and response to intervention from referral to discharge
-Serves as an information source for client care, can be used by a covering
therapist in absence of primary therapist
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research,
education and reimbursement
, Guidelines for Documentation include information that is: - ANSWER (1)
Factual
(2) Accurate
(3) Complete
(4) Current
(5) Organized
Factual documentation is - ANSWER descriptive and objective
is free of judgement and personal opinions
creates a clear picture
documents what you see, hear, smell and feel
Documentation is accurate by: - ANSWER providing exact measures
being brief & concise (only documenting activity that is specific)
using appropriate terminology with approved abbreviations
use of correct spelling (shows a level of competency)
date and signature
A document is COMPLETE when - ANSWER - you follow facility
guidelines/format/standards
Test With Solution
Documentation (def.) - ANSWER anything written or printed; record of proof
of patient actions or activities
Documentation must.... - ANSWER - be accurate, comprehensive and easily
retrievable
- show continuity of care
- track patient outcomes
- reflect current standards of nursing practice
Purpose of documentation: - ANSWER -Provides a legal, serial record of
client's condition, evaluation and re-evaluation results, course of therapeutic
intervention and response to intervention from referral to discharge
-Serves as an information source for client care, can be used by a covering
therapist in absence of primary therapist
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research,
education and reimbursement
, Guidelines for Documentation include information that is: - ANSWER (1)
Factual
(2) Accurate
(3) Complete
(4) Current
(5) Organized
Factual documentation is - ANSWER descriptive and objective
is free of judgement and personal opinions
creates a clear picture
documents what you see, hear, smell and feel
Documentation is accurate by: - ANSWER providing exact measures
being brief & concise (only documenting activity that is specific)
using appropriate terminology with approved abbreviations
use of correct spelling (shows a level of competency)
date and signature
A document is COMPLETE when - ANSWER - you follow facility
guidelines/format/standards
