NURSING DOCUMENTATION TEST QUIZZES 100%
SOLVED CORRECT!
What is Documentation?
Anything written or electronically generated that describes the status of a patient or the care or
service given to the patient
What are the SIX Purposes of Pt. Records?
1. Communication & Care Planning
2. Legal Documentation
3. Education
4. Funding & Resource Management
5. Research
6. Quality Review
Communication & Care Planning
- All HCT members communicate pt. needs, progress, care, treatments and education
- Starts on admission and ends at discharge of pt.
, - Ensure consistency & continuity of care
- Reflects the nursing process
- Provides baseline data
Education
- Pt. is unique
- Nurses & students can learn about illness and patterns of behavior
- Enables students to see patterns & types of care provided/needed
Legal Documentation
- Demonstrates accountability for practice
- Best defence against legal claims
- "Care not documented is care not given"
- Need to document assessments, care, pt. responses, instructions & referrals etc.
Funding & Resource Management
SOLVED CORRECT!
What is Documentation?
Anything written or electronically generated that describes the status of a patient or the care or
service given to the patient
What are the SIX Purposes of Pt. Records?
1. Communication & Care Planning
2. Legal Documentation
3. Education
4. Funding & Resource Management
5. Research
6. Quality Review
Communication & Care Planning
- All HCT members communicate pt. needs, progress, care, treatments and education
- Starts on admission and ends at discharge of pt.
, - Ensure consistency & continuity of care
- Reflects the nursing process
- Provides baseline data
Education
- Pt. is unique
- Nurses & students can learn about illness and patterns of behavior
- Enables students to see patterns & types of care provided/needed
Legal Documentation
- Demonstrates accountability for practice
- Best defence against legal claims
- "Care not documented is care not given"
- Need to document assessments, care, pt. responses, instructions & referrals etc.
Funding & Resource Management
