Nursing Documentation Flashcards
Why document?
Facilitates communication among professionals, providers, and all team members promoting coordination of care
- provides data source for quality assurance
- reflects quality and timeliness of nursing care
- legal document and record of care for an individual
Nursing documentation
A permanent legal document that provides a comprehensive account of information about the individual’s health care status
Documentation reflects: nursing assessment
- creates baseline
- identified health problems are reviewed in a regular fashion and a timely basis until resolved
- resolution should be documented
- includes normal and abnormal
Diagnostic reasoning
Documentation reflects individuals health status based on nursing assessment and nursing diagnosis
Planning
Documentation reflects the plan of care to meet needs/problems
Implementation
Includes health status or problem, treatment rendered, and individual response to treatment
-consistent with plan of care
Evaluation
Documentation reflects evaluation of nursing interventions and their outcomes, which creates a new baseline
When to document?
- after intervention
- medication administration record
- never before medications, treatments, interventions
What to document?
Tell patients story
Date and times
Signs and symptoms
Use pt own words and non verbal cues
-all contacts with other healthcare providers, info communicated, what occurred
- response to an medication, treatment, intervention
- routine or ongoing treatment
- any action taken In response to problem
-do not document actions done by other people
- patient refusal of care/treatment
How to document
Tell story
Date and time of entry
Time of observation or intervention
If written: black ink
No blank spaces between entries, draw line to end of space if entry does not completely fill space
Use approved abbreviations
Objective
Direct quotes for patient words
Interpretations should be supported by descriptions of specific observations
Never white out, erase or obliterate from record
If you make a mistake in entry..
Draw single line, write above the date, time, and initials
Late entries
Use the date and time of actual entry, followed by the date and time of undocumented care,intervention, or treatment followed by the words “late entry”
Sign all entries with?
First initial, last name, credentials
