Tanisha Wilson

October, 24, 2012

Wharton Country Junior College-Sugarland

KEY DOCUMENTATION IN NURSING DOCUMENTATION

Objectives: The student will identify at least three purposes of a health care record by the end of my presentation . The student will describe at least three methods for interdisciplinary communication within the health care team by the end of my presentation. The student will identify at least three ways to maintain confidentiality of electronic and written records by the end of my presentation .

Purposes of a Health Care Record

Prevention of medical errors Communication with other healthcare providers Demonstrate the delivery of care Ensure appropriate reimbursement Demonstrate adherence to accreditation standards Provide evidence in legal proceedings Promote knowledge development through research

Principles of Effective Documentation

Elements of nursing process needed to
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be made evident in documentation include: Assessment. Nursing Diagnosis. Planning and outcome identification.

Implementation. Evaluation. Revisions of planned care.

Elements of Effective Documentation

To ensure effective documentation, nurses should:
Use a common vocabulary. Write legibly and neatly. Use only authorized abbreviations and symbols.

Employ factual and timesequenced organization. Document accurately and completely, including any errors.

Elements of Effective Documentation

To ensure effective documentation, nurses should:
Use a common vocabulary. Write legibly and neatly. Use only authorized abbreviations and symbols.

Employ factual and timesequenced organization. Document accurately and completely, including any errors.

Good Documentation Examples

Patient A is experiencing 8/10 pain unrelieved by hydrocodone 500mg/5mg q 6 hours. Last dose given 1 hour ago. States he is in constant agony and exhibits angry behavior towards others. Patients Bs wife confided that her husband is anxious about an upcoming lung biopsy and fears that he has cancer. His father had the same symptoms at his age and died from lung cancer. Patient C states her pain is 0/10. States she hasnt been pain-free in over a year now and is so grateful for her new care and treatment.

Interdisciplinary Communication

Who reads nursing records?

Nurses Patients Relatives Doctors Members of the health care team

http://www.youtube.com/watch?v=F_FgGyQS50 8

Patient Confidentiality

Patient Teaching