What is proper documentation in nursing?
Proper documentation in a patient’s chart tells a chronological story about their care and health status. It allows for all team members to remain updated and connected on the plan of care for patients and how the patient is responding to that plan (Mathioudakis et al., 2016).
What is included in nursing documentation?
Nursing documentation is defined as the process of preparing a complete record of handwritten or electronic evidence regarding a patient’s care. It includes nursing assessment, nursing care plan (highlighting the patient’s healthcare needs and outcomes), along with interventions, education, and discharge planning.
What is timely nursing documentation?
1) Timeliness of electronic nursing records Timeliness refers to an appropriate time in which information regarding an event must be used before it loses its ability to influence the decision-making process.
What is computerized charting?
the keeping of a clinical record of the important facts about a patient and the progress of his or her illness.
What are the general guidelines for nursing documentation?
In addition, general guidelines to follow include: Always assess the patient at the time of discharge or transfer. It’s vital to know the status of a patient before he leaves or enters your care. Always use a chronologic documentation format, providing separate entries for each narrative item.
What does documentation mean in a medical record?
Documentation is not merely “record keeping”; the documentation that comprises a patent’s medical record is also a legal document. Documentation is therefore a means for others to assess whether the care that a patient received met professional standards for safe and effective nursing care, or not. “If it wasn’t documented, it wasn’t done.”
When to use ” mistaken entry ” or ” error ” in nursing documentation?
If you need to indicate that you’ve made a change, simply write “mistaken entry” and avoid using words like “error,” which can suggest that you made a nursing or medical error that jeopardized patient safety.
What to write on a nursing Note If patient is rude?
If a patient is rude, inappropriate or even hostile, don’t record those subjective judgments in your notes; instead write, “Patient made verbal threats toward myself and other staff members; per hospital’s safety protocol, security personnel called to patient’s room.”