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Tanisha Wilson

October, 24, 2012

Wharton Country Junior College-Sugarland

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KEY DOCUMENTATION INNURSING DOCUMENTATION

Objectives:

The student will identify at least three purposes of ahealth 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 writtenrecords by the end of my presentation .

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Purposes of a Health

Care Record

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•Prevention of medical errors•Communication with other healthcareproviders•Demonstrate the delivery of care

•Ensure appropriate reimbursement•Demonstrate adherence to accreditationstandards•Provide evidence in legal proceedings

•Promote knowledge development throughresearch

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Elements of nursing process needed to

be made evident in documentation include:.

Principles of Effective Documentation

●Assessment.

●Nursing Diagnosis.

●Planning andoutcome

identification.

●Implementation.

●Evaluation.

●Revisions ofplanned care.

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Elements of Effective Documentation

To ensure effective documentation, nurses should:

●Use a common vocabulary.

●Write legibly and neatly.●Use only authorizedabbreviations and symbols.

●Employ factual and time-

sequenced organization.●Document accurately andcompletely, including anyerrors.

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Elements of Effective Documentation

To ensure effective documentation, nurses should:

●Use a common vocabulary.

●Write legibly and neatly.●Use only authorizedabbreviations and symbols.

●Employ factual and time-

sequenced organization.●Document accurately andcompletely, including anyerrors.

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 Patient A is experiencing 8/10 pain unrelieved by hydrocodone 500mg/5mg q6 hours. Last dose given 1 hour ago. States he is in constant agony andexhibits angry behavior towards others.

Patient’s B’s wife confided that her husband is anxious about an upcoming

lung biopsy and fears that he has cancer. His father had the same symptomsat his age and died from lung cancer.

Patient C states her pain is 0/10. States she hasn’t been pain-free in over ayear now and is so grateful for her new care and treatment.

Good Documentation Examples

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Interdisciplinary

Communication

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Who reads nursing records?

●Nurses

●Patients

●Relatives

●Doctors●Members of the health care team

http://www.youtube.com/watch?v=F_FgGyQS508

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Patient

Confidentiality

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Patient

Teaching

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