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
