Documentation

Question 1

What is the purpose of a client’s record

Answer 1

-facilitating interprofessional communication among healthcare professionals
-providing legal record of care provided
-justification for financial billing and reimbursement of care
-Used to audit, monitor, and evaluate care provided to support need for improvement
-Resource for education and research
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Question 2

What are the standards for nursing documentation?

Answer 2

• Factual - avoid good, normal, “appears to be, seems to be, etc”
• Accurate - exact measurement and proper spelling
• Appropriate use of abbreviations
• Current -
• Organized - timely
• Complete - time, date, and sign everything

Question 3

Other guidelines for documentation?

Answer 3

• No blanks left, add important details
• Corrections and Omissions
• Only chart for yourself (confidentiality)
• Don’t double chart
• Don’t chart in all capital letters

Question 4

What are some methods of documentation?

Answer 4

• Flowsheets - graphic records organized by body system
• Progress Notes - focus charting, (DAR) data, action, response, (SOAP) interprofessional problems, (PIE) identifying nursing problems or diagnoses

Question 5

What is Narrative documentation?

Answer 5

format traditionally used by nurses and health care providers to record patient assessment, clinical decisions, and care provided

Question 6

What are some common record keeping forms within electronic health records?

Answer 6

Admission Nursing History Form
Patient Care Summary
Care Plans
Discharge Summary Forms