Documentation W13

Question 1

What is documentation ?

Answer 1

It is any written or electronically generated information about a client that describes the care or service provided
It is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses

Question 2

What are the purposes of documentation ?

Answer 2

1. Communication
2. Safe and appropriate nursing care
3. Professional and legal standards

Question 3

What are the legal issues with documentation ?

Answer 3

• the patient record is a permanent legal document
• it may be used to provide evidence in court
• in court, care not documented is care not received*
• FIPPA

Question 4

What are some of the documentation principles?

Answer 4

• only use BLACK ink
• only document care PERSONALLY PROVIDED
• document ASAP in chronological order
• do not leave blank spaces, or lines
• RPNs must add their signature and designation in a legible manner

Question 5

What are the common documentation forms ?

Answer 5

• initial assessment/admission forms
• nursing care plan
• flow sheets
• nursing notes
• Kardex
• Incident reports (not apart of the health record)

Question 6

What is Kardex?

Answer 6

It makes information readily available, and it is continuously updated in pencil. it is NOT a legal document
It may include allergies, treatments, goals, MH status, pertinent information

Question 7

What to chart ?

Answer 7

• status and health concerns of the patient
• changes in status (MSE)
• nursing care and interventions
• patient responses and evaluate the effectiveness of the care provided
• the effectiveness of medications and prn medications

Question 8

What are the types of charting ?

Answer 8

Narrative: written chronologically in PARAGRAPH form in progress notes
Problem-oriented by Exception: it is often seen with checklists DARP/SOAP(IE)
Data Action Response Plan
Subjective Objective Assessment Plan

Question 9

What is the purpose of incident reports?

Answer 9

These document unusual, unanticipated occurrences as a risk management tool
EX. medication errors, falls

Question 10

What are some of the common errors of documentation ?

Answer 10

• no date, time, or signatures
• illegible handwriting
• leaving blank spaces
• using SUBJECTIVE language
• using inappropriate abbreviations