Introduction - Documenting and Reporting Flashcards
A nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record.
Documentation
D___ within a patient health care record is a vital aspect of nursing practice.
D-ocumentation
Nursing documentation needs to be a___ and comprehensive.
a-ccurate
Nursing documentation s___ need to be flexible enough to retrieve clinical data, facilitate continuity of care, track patient outcomes, and reflect current standards of nursing practice.
s-ystems
Information in a patient’s record provides a detailed account of the level of ___ of care delivered.
quality
The quality of care, the standards of regulatory agencies and nursing practice, and legal guidelines make ___ and reporting an extremely important nursing responsibility.
documentation
Effective ___ can positively affect the quality of life and health outcomes for patients and minimize the risk of errors.
documentation
As a member of the health care team, the nurse needs to communicate information about patients accurately and in a t___, effective manner.
t-imely
True or false: if the care plan is not communicated to all members of the health care team, care can be fragmented, tasks repeated, and therapies delayed or omitted.
True
True or false: data recorded, reported, or communicated to other health care providers are confidential, and the confidentiality of these data must be protected.
True
