15 - Documentation

Question 1

The 8 Common Documentation Errors

Answer 1

1) Failure to record pertinent health or drug information
2) Failure to record nursing actions
3) Failure to document meds
4) Failure to document discontinued meds
5) Failing to record drug reaction/interactions
6) Transcribing orders improperly
7) Documenting on wrong chart
8) Writing ineligibly

Question 2

Guidelines for Electronic and Written Documentation

Answer 2

• Do not document retaliatory or critical comments about a patient or care provided by another health care provider.
• Do not enter personal opinions.
• Correct all errors promptly.
• Record all facts.
• Document as close as prudently possible to the time of the event.
• If an order is questioned, record that clarification was sought.
• Document only for yourself.
• Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
• Begin each entry with the date and time and end with your signature and credentials.
• Avoid “precharting” (documenting an entry before performing a treatment or an assessment or before giving a medication).
• Protect the security of your password for computer documentation.
• Do not erase, apply correction fluid to, or scratch out errors made while recording.
• Do not leave blank spaces or lines in a written nurse’s progress notes.
• Record all entries legibly and in black ink. Do not use felt-tip pens or erasable ink.

Question 3

Guidelines for Quality Documentation

Answer 3

Factual
Accurate
Complete
Current 
Organized
Compliant with standards

Question 4

Documentation in Home Health Care

Answer 4

• Patient and family guardian of information

* A hard copy of the health care record is kept in the patient’s home.

Question 5

Documentation in the Long-Term Health Care Setting

Answer 5

Documentation is used to review levels of care given to and needed by residents in long-term care facilities.

Question 6

Critical Thinking Skills

Answer 6

Interpretation
Analysis
Inference
Evaluation
Explanation
Self-regulation

Inference: making education guesses. Looking at the meaning and patterns and make an guess
Evaluation: did it work? Does there still need to be some change?
Explanation: supporting findings and conclusions
Self-Regulaition: reelect on experiences, applied ethical principles and reflect on ways to improve performance

Question 7

Critical Thinking Dispositions

Answer 7

• Truth-seeking: find out what’s actually happeing in a situation (even if it doesn’t support your own belifs)
• Open-mindedness: tolerat of others belifs and views
• Analyticity : determine significance of sitiation
• Systematicity: being organized and focused in data collecition
• Self-confidence: need to be able to trust yourself and also be willing to exept other things
• Inquisitiveness
• Maturity

Question 8

Kataoka-Yahiro and Saylor’s (1994) critical thinking model

Answer 8

Basic critical thinking
Complex critical thinking
Commitment

Question 9

Components of Critical Thinking in Nursing

Answer 9

Specific knowledge base
Experience in nursing
Critical thinking competencies
Attitudes for critical thinking
Standards for critical thinking

Question 10

Nursing Process - 5

Answer 10

Assessment
Diagnosis
Planning
Implementation
Evaluation