Components of Good Documentation Flashcards
1
Q
Components
A
Who
2
Q
What
A
Assessment findings?
pts complaint
care you provided
3
Q
when
A
the time when you provided care
4
Q
Where
A
where did event take place
where was the treatment given or medication administered
5
Q
How
A
How was the treatment completed?
How did the resident tolerate the procedure/treatment
6
Q
Outcome
A
Outcome of the procedure/treatment
7
Q
Follow-up
A
what type of follow-up needed (retaking BP, pain level…)
8
Q
Accuracy
A
exact measurements (don’t use about or approx.)
