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10 Cards in this Set
- Front
- Back
Documentation is:
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the written or typed legal record of all pertinent interactions with the patient—
assessing, diagnosing, planning, implementing, and evaluating. |
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The patient record is:
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a compilation of a patient’s health information.
The patient record is the only permanent legal document that details the nurse’s interactions with the patient and is the nurse’s best defense if a patient or patient surrogate alleges nursing negligence. |
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Aim of Documentation is to be:
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Complete,
accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. |
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The content of the documentation should be entered in a :
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complete, accurate, concise, current,and factual manner and reflects the nursing process and your professional responsibilities.
Record patient findings (observations of behavior) rather than your interpretation of these findings. |
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Documentation should avoid words such as:
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“good,” “average,” “normal,” or“sufficient,” which may mean different things to different readers.
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Documentation should avoid generalizations such as:
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“seems comfortable today.”
A better entry would be: “on a scale of 1 to 10, patient rates back pain 2 to 3 today as compared with 7 to 9 yesterday; vital signs returned to baseline.” |
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Documentation should Note problems as they occur in an:
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orderly, sequential manner;
record the nursing intervention and the patient’s response;update problems or delete as appropriate. |
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Documentation should Chart:
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any precautions or preventive measures used.
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Document all medical visits and consultations of which other nurses should be aware, either because:
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of their impact on the patient or because of the nursing care the patient now requires.
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Document in a legally prudent manner.
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Know and adhere to professional standards and agency/institutional policy for documentation.
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