NSCN Documentation for Nurses Flashcards
Definition of Documentation
Documentation refers to written or electronic records detailing client care, including assessments, interventions, and evaluations. It’s mandatory and essential to nursing practice.
Understand the Essential Characteristics of Nursing Documentation
- Factual and Objective: All documentation should rely on observed, measurable, or fact-based information, avoiding subjective opinions or assumptions.
- Accurate and Relevant: Details provided must be clear, precise, and directly related to client care, avoiding unnecessary or vague language.
- Complete: Includes all components of the nursing process, noting interventions and client responses.
- Current: Documentation should be done promptly after interventions to reflect real-time care.
- Organized: Information must be logically arranged chronologically to convey a clear progression of the client’s care.
- Compliant with Standards and Legal Requirements: Documentation must adhere to standards of practice, legal obligations, and the facility’s policies to protect both the nurse and client.
Understand the main points of Confidentiality
-Confidentiality is central to the ethical practice of nursing. It ensures that client information is accessible only to individuals directly involved in care.
-Nurses must store records securely, prevent unauthorized access, and follow guidelines on the appropriate release of client information. Breaches of confidentiality can lead to professional misconduct charges.
Understand the purpose and rationale behind why we document
- Communication: Documentation helps exchange critical information among care team members.
- Continuity of Care: Detailed and accurate records support the development of comprehensive care plans, minimizing task repetition and potential delays.
- Professional Accountability: Nurses’ expertise and judgment are demonstrated through their records, upholding standards and ethical responsibilities.
- Legal: Health records may serve as legal evidence, showing actions taken and client interactions in cases of disputes or professional investigations.
- Quality Assurance: Documentation enables audits and reviews to assess service quality and identify improvement opportunities.
- Funding and Resource Management: Records can inform decisions about resource allocation based on client needs and workload measurement.
- Research: Documentation provides valuable data for evaluating care effectiveness, interventions, and outcomes
Understand the meaning behind the role of the “firsthand knowledge”, “designated recorder,” and “students” sections
- Firsthand Knowledge: Nurses are responsible for documenting only the care they provide. Primary caregivers should document, but in cases where multiple providers are involved, they may add entries as needed for clarity.
- Designated Recorder: In emergencies (e.g., cardiac arrest), a designated recorder may document actions while others deliver care.
- Students: Nursing students must follow agency policies for documentation, but their notes should not be co-signed by supervising nurses, who instead document their own assessments if necessary.
When should you cosign, and when should you not cosign in documentation?
-Cosigning is required only when both healthcare providers participated in or witnessed an event.
-For instance, both nurses may sign when verifying blood transfusions.
-However, cosigning does not apply to student documentation, which the supervising nurse should document separately based on professional judgment.
How does the nursing process apply to documentation?
- Assessment: Observations, measurements, and client statements.
- Diagnosis: Clinical judgments based on assessments.
- Planning: Goals and outcomes expected from interventions.
- Implementation: Steps taken to meet planned outcomes.
- Evaluation: Analysis of client responses to care and any adjustments needed.
- Documenting the nursing process ensures comprehensive records that support client-centered, holistic care
How do you document Serious Reportable events?
*SREs are adverse events that deviate from expected care and include patient falls, medication errors, and injuries.
*SREs must be documented clearly, factually, and objectively without terms such as “error” or “incident.”
*Per policy, SREs must be documented in both the health record and an SRE report.
Understand the following: Objectivity vs. Subjectivity; Generalizations; Bias and Labels; Risk-taking Behaviors; Errors and Changes
- Objectivity: Documentation should focus on observable facts (e.g., “Client was crying”) instead of interpretations (e.g., “Client was upset”).
- Subjectivity: If subjective information is necessary, quote the client’s statements directly (e.g., “Client states, ‘I feel dizzy’”).
- Avoiding Generalizations: Avoid vague phrases like “doing well” or “no change”; provide specific observations instead.
- Avoiding Bias and Labels: Describe behavior factually (e.g., “client was speaking loudly” instead of “client was aggressive”) and avoid terms that carry judgment or bias.
Understand why we document “Timely, Chronologically and Frequently
-Documentation should be recorded as close to the time of events as possible, chronologically, and with a frequency that reflects the client’s condition.
-Timely entries ensure records are accurate and reduce potential risks associated with delayed documentation
