Module 4 - Documentation and Reporting

Question 1

Purpose of documentation

Answer 1

Written account/data of patient data, nursing decisions, clinical decisions, interventions and patient responses

• Communication tool exchanging of client care information
• Research
• Can be used and examined by a court if necessary

Question 2

Principles for Documentation

Answer 2

• Avoid personal comments
• Client focused
• Record all facts
• Correct all errors
• Time focused
• Document only for yourself
• Date/Time and Initials
• No blank spaces
• Policy and procedures
• ADPIE

Question 3

Accurate Documentation

Answer 3

Use of exact measurements and it more accurate

ex) client intake, 360 mL of water
- Concise and clear
- Correct spelling
- Dated entries/credentials
- Accountability

Question 4

In-Accurate Documentation

Answer 4

• Unnecessary words
• Irrelevant data
• Abbreviations/Symbols
• Incorrect spelling
• Late entries

Question 5

Written Documentation

Answer 5

Done by hand:

• Episode orientated
• Time consuming
• Separate records for each visit
• Less collaboration
• Must be written in black pen
• Can contain mistakes
• Messy handwriting

Question 6

Electronic Documentation

Answer 6

EHR (Electronic Health Record) - Patient Data

• EMR (Electronic Medical Record) - Legal Record
• Effective
• Fast input
• Collaboration is easier
• Integration of all patient data
• Tracked by other healthcare providers
• Links to resources
• Secure and Safe
• Continuous access to authorized users at the same time

Question 7

Documentation within Legal Process

Answer 7

• Legal claims
• Proof of healthcare provided
• Vital evidence in lawsuits
• Did the client receive the best/appropriate care?
• Indication of ADPIE

Question 8

Nurse responsibilities with healthcare technology and EHR

Answer 8

• Factual
• Accurate
• Complete
• Current Inter professional communication
• Meets legal and regulation requirements
• Quality improvements