Week 8 Flashcards
Why do we document?
It is a safe and effective practice, records the nurse’s critical thinking & judgement, and account of nurse’s actions.
What is documentation?
Anything written or electronically generated that describes the status of a client or the care/service given to a client.
What are the purposes of documentation?
- Communication
- Accountability
- Legislative requirement
- Research
- Funding
- Quality improvement
Who should document?
Nurses should document the care they provided. If they are documenting for others include name/title and what they saw or did.
T or F, Hospital records should be retained for 5 years.
False
T or F, A client has a right to access the record.
True
T or F, A Kardex is always a permanent record.
False
T or F, Abbreviations should never be used.
False
T or F, Late entries must be clearly marked.
True
T or F, Document A.S.A.P. after the event.
True
Communication between health care providers is important in patient care. What must the nurse do in order to ensure that there is adequate communication?
Provide accurate, detailed, objective, and timely information.
What is a worksheet used for?
Used to organize time & priorities.
What is a Kardex used for?
To communicate current orders.
There are different methods of recording. What are they?
- SOAP
- SOAPIE
- PIE
- Focus charting (DAR)
What does SOAPIE stand for?
- Subjective
- Objective
- Assessment
- Planning
- Intervention
- Evaluation
