Documentation part 1 Flashcards
What is documentation?
any written or electronically generated information about a client that describes the care or service provided to that client
What are the 6 purposes of pt. records?
COMMUNICATION & CARE PLANNING
LEGAL DOCCUMENTATION
EDUCATION
FUNDING & RESOURCE MANAGEMENT
RESEARCH
QUALITY REVIEW
How does documentation improve communication and care planning?
- All health care members communicate pt needs, progress, care, tx, and education
- ensures consistency and continuity of care
- provides baseline data
What does documentation do in terms of the benefit of being a legal document?
- demonstrates accountability
- best defense against legal claims
- care not documented is care not given
- need to document assessments, care, pt. responses, instructions, referrals
What is the purpose of documentation in terms of education?
- nurses/students can learn about illness and patterns of behaviour
- enables student to see patterns and types of care provided/needed
- helps to understand the uniqueness of each pt.
What is the purpose of documentation in terms of funding and resource management?
- shows how HC resources have been used
- level of acuity of pt indicates the type and of resources required
What is the purpose of documentation in terms of research?
- provides data for statistical purposes
- analysis of data for research purposes
what is the purpose of documentation in terms of quality review?
- evaluation of the quality and appropriateness of care
- audit chart after discharge or while pt is in hospital
- allows other disciplines to work together
- deficiencies are shared and results in change of practice/policies
what are the 6 guidelines for quality documentation?
1) Factual information
2) Accurate
3) Complete
4) Current
5) Organized
6) complies with standards
What should you ensure your documentation is like to be factual?
descriptive, objective
non-judgmental
no inferences without supporting data
avoid: appears, seems, apparently
Subjective data needs to have quotations and be as exact as possible
What should you ensure your documentation is like to be accurate?
accurate and specific time, amount, size, description, response
spelling
initials/signature and status after each timed charting entry
if there is an error, signal line through it, above “charting error” and initials
“Late entry” addendum to note of Jan. 13/12
any blank spaces need to have a line through them
What does telegraphic mean?
certain words may be omitted to allow quick and rapid transmission
What are some abbreviations to avoid?
U, IU, abbreviated drug names, @
QD or OD use daily
QOD use every other day
OS, OD, OU write it out
D/C use discharge
< and > use words
NEVER use 0 by itself after a decimal
ALWAYS use 0 before a decimal (0.5 not .5)
How can you ensure your documentation is complete?
make sure it includes all of the pt’s status, care given and response to care
ensure appropriateness
What does it mean to have current documentation?
timely entries
make sure data is recorded at time of occurrence (never before hand) ex med admin, tx’s, prep for tests/surgery, change in status, admission, death
