Lesson 7 - Documentation Flashcards
Why do nurses document?
-legal evidence
-records
-communication
-funding and resource management
-auditing and monitoring
-education
-care-planning
-research
What do nurses document?
-everything THEY do
Precharting
-documenting an entry before doing
-don’t do
-invites error
-falsification of records
When to document?
-during or after care
Erasing
-do not do
-correct and scratch out errors
-becomes illegible and may appear as if you were hiding info
Blank Spaces
-do not do
-allows another person to add info
-draw a horizontal line through spaces
-sign with credentials at the end
Ink
-use black ink
-no felt tip pens or erasable ink
Questioned Orders
-record that clarification was sought
-don’t say “physician made error”
-note who you spoke with and the outcome
Individual Documentation
-only document what you did
Beginning and End
-begin with date and time
-end with signature and credentials
-ie. Bob Ross, RN
Retaliatory Comments or Opinions
-do not document
-may be used as evidence for unprofessional behaviour
-only enter objective info and facts
-quote patient statements
Correct Errors
-promptly
-don’t rush documentation to avoid errors
Safety Incidents and RLS Reports
-do not refer to them in the medical chart
Trials
-can take 5-10 years to complete
-if you don’t document what you did, will you remember?
Confidentiality
-dispose of records properly
-log out of WOW when stepping away
-don’t talk about pt in public
Good Documentation is…
-factual
-accurate
-complete
-current
-organized
-compliant to standards
AHS Date, Time, Signature
-day, month, year ie. 05 MAR 2024 (not 05/03/24!)
-time is 24 hour clock
-signed
MacEwan Date, Time, Signature
-ie. M. O’Neill, NS MacEwan
SOAP
-narrative documentation
-subjective
-objective
-assessment
-plan
PIE
-narrative documentation
-problem
-intervention
-evaluation
DAR
-narrative documentation
-data
-action
-response
Electronic Records
-lifetime record
-stored and tracked info
-imaging and lab results easily accessible
-netcare and connect care
SBAR
-situation
-background
-assessment
-recommendation
IDRAW
-ID patient
-diagnosis
-recent changes
-anticipated changes
-what to watch for
