Taylor - Fundamentals Of Nursing - Adn 1 Exam #3 Chapter 17 -Documenting

Front 1

Documentation is:

Back 1

the written or typed legal record of all pertinent interactions with the patient—
assessing,
diagnosing,
planning,
implementing, and
evaluating.

Front 2

The patient record is:

Back 2

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.

Front 3

Aim of Documentation is to be:

Back 3

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.

Front 4

The content of the documentation should be entered in a :

Back 4

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.

Front 5

Documentation should avoid words such as:

Back 5

“good,” “average,” “normal,” or“sufficient,” which may mean different things to different readers.

Front 6

Documentation should avoid generalizations such as:

Back 6

“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.”

Front 7

Documentation should Note problems as they occur in an:

Back 7

orderly, sequential manner;
record the nursing intervention and the patient’s response;update problems or delete as appropriate.

Front 8

Documentation should Chart:

Back 8

any precautions or preventive measures used.

Front 9

Document all medical visits and consultations of which other nurses should be aware, either because:

Back 9

of their impact on the patient or because of the nursing care the patient now requires.

Front 10

Document in a legally prudent manner.

Back 10

Know and adhere to professional standards and agency/institutional policy for documentation.