Documentation and Reporting - Unit 1 Flashcards
Documentation - def
The written, legal record of all pertinent interactions with the patient - assessing, diagnosing, planning, implementing, and evaluating.
Patient Record - a ___ of a patient’s health information.
Compilation.
JCAHO specifies that nursing care, data related to patient assessments, nursing diagnoses, nursing interventions, and patient outcomes be permanently integrated into the patient record. T/F?
True!
What are some purposes of patient records?
Communication, care planning, quality review, legal documentation, research, historical documentation, reimbursement, education and decision analysis.
Guidelines for Recording - Timing -
for each notation, documentation of the date and time of the recording and of the assessment or intervention is essential.
Document whenever you want. T/F?
False - do it as soon as possible!
Recording can be done before providing care. T/F?
False! You need to do it ONLY after you’ve done something!
Guidelines for recording - confidentiality - def
The patient’s record is protected legally as a private record of the patient’s care.
Permanence - def - all entries…
all entries on the client’s record are made in dark colored (BLACK) ink so that the record is permanent and changes can be identified.
We don’t need to sign the recording’s. T/F?
False - we do need to!
Accuracy - it is essential that…
all notations on the record be accurate and correct.
We need to quote ___, avoid __ words, spell ___, draw a line through an __ and initial it, and draw a line through all ___ spaces.
Direct.
Avoid general words.
error.
blank.
Recording - sequence - the nurse documents events in the order in which they…
occur!
Appropriateness - only information that pertain to the patient’s health problem and care is recorder. T/F?
True!
Don’t use standard terminology - T/F?
False - use it!
