CNO - Documentation Flashcards
Whether paper, electronic, audio or visual - it is used to monitor a client’s progress and communicate with other care providers. It also reflects the nursing care that is
provided to a client.
Documentation
Reflects the client’s perspective, identifies the caregiver, and promotes continuity of care by allowing other partners in care to access the information.
Doccumentation
Communicates to all health care providers the plan of care, the assessment, the interventions necessary based on the client’s history, and the effectiveness of those interventions.
Documentation
Demonstrates the nurse’s commitment to providing safe, effective, and ethical care by showing accountability for professional practice, showing the care the client receives, and transferring knowledge about the client’s health history.
Documentation
Demonstrates that the nurse has applied within the therapeutic nurse-client relationship the nursing knowledge, skill, and judgment required by professional standards regulations.
Documentation
Whether documenting for individual clients, or for groups or communities, the documentation should provide a clear picture of:
■ the needs or goals of the client or group
■ the nurse’s a___ based on the needs assessment
■ the outcomes and e___ of those actions.
a-ctions
e-vauluation
Can be used to evaluate professional practice as part of quality improvement processes.
Data from documentation
Can be used to determine the care and services a client requires or was provided.
Data from documentation
Through this, nurses can review outcome information to reflect on their practice and identify knowledge gaps that can form the basis of learning plans.
Data from documentation
In nursing research, ___ from documentation is used to assess nursing interventions, evaluate client outcomes, identify care, and documentation issues, and advance evidence-based practice.
data
True or false: nurses are required to make and keep records of their professional practice.
True
As regulated health care professionals, nurses are accountable for ensuring that their documentation is accurate and meets the ___ practice standards.
College’s
Failing to keep records as required, falsifying a record, signing or issuing a document that the member knows includes a false or misleading statement, and giving information about a client without consent, all constitute professional ___ under the Nursing ___.
misconduct / Act
Nursing documentation may be accessed in ___ investigations and other legal proceedings.
College
The diagram illustrates the inter-relationships supporting nurses in the provision of safe, effective, and ethical care.
The ___ fact sheets, practice standards, and guidelines support nurses in the provision of safe, ethical, and effective care.
College’s
Support nurses with policies, procedures, and decision-support tools.
Organizations