Week three: Documentation

Question 1

what are the purposes of records?

Answer 1

• legal document
• communication and care planning
• quality assurance
• education
• research

Question 2

what are the three principles for governing documentation

Answer 2

1. confidentiality
   - keeping info private
2. accurate and complete
   - what is observed, heard, auscultated, palpated, per-cussed/smelled
   - abbreviations
   - error correction
3. accurate and complete
   - organized
   - timely
   - concise
   - clinical judgement

Question 3

what are soap notes?

Answer 3

*focuses on a single problem and includes:
S-subjective assessment findings
O-objective assessment findings
A-analysis of the assessment data to identify and track problem
P-Plan for treatment

Question 4

what is charting by exception?

Answer 4

• predetermined criteria for nursing assessments and interventions, using defined standards or practice
• only significant findings to these predefined norms are documented in writing
• assumption is that all standards are met unless otherwise documented

Question 5

what are the three standard statements for documentation?

Answer 5

1. communication - nurses ensure documents are accurate, clear, and comprehensive for client needs
2. accountability - accountable for ensuring their documentation of care that is accurate, timely and complete
3. security - maintain confidentiality annd act in accordance with information retention and destruction policies and procedures that are consistent