Module 4 - Documentation and Reporting Flashcards
1
Q
Purpose of documentation
A
Written account/data of patient data, nursing decisions, clinical decisions, interventions and patient responses
- Communication tool exchanging of client care information
- Research
- Can be used and examined by a court if necessary
2
Q
Principles for Documentation
A
- Avoid personal comments
- Client focused
- Record all facts
- Correct all errors
- Time focused
- Document only for yourself
- Date/Time and Initials
- No blank spaces
- Policy and procedures
- ADPIE
3
Q
Accurate Documentation
A
Use of exact measurements and it more accurate
ex) client intake, 360 mL of water
- Concise and clear
- Correct spelling
- Dated entries/credentials
- Accountability
4
Q
In-Accurate Documentation
A
- Unnecessary words
- Irrelevant data
- Abbreviations/Symbols
- Incorrect spelling
- Late entries
5
Q
Written Documentation
A
Done by hand:
- Episode orientated
- Time consuming
- Separate records for each visit
- Less collaboration
- Must be written in black pen
- Can contain mistakes
- Messy handwriting
6
Q
Electronic Documentation
A
EHR (Electronic Health Record) - Patient Data
- EMR (Electronic Medical Record) - Legal Record
- Effective
- Fast input
- Collaboration is easier
- Integration of all patient data
- Tracked by other healthcare providers
- Links to resources
- Secure and Safe
- Continuous access to authorized users at the same time
7
Q
Documentation within Legal Process
A
- Legal claims
- Proof of healthcare provided
- Vital evidence in lawsuits
- Did the client receive the best/appropriate care?
- Indication of ADPIE
8
Q
Nurse responsibilities with healthcare technology and EHR
A
- Factual
- Accurate
- Complete
- Current Inter professional communication
- Meets legal and regulation requirements
- Quality improvements
