Documentation for Nurses
After completing this course, youíll be able to:
Evaluation of Individual
Objectives To assess the effectiveness of the course material, we ask that you evaluate your achievement of each learning objective on a scale of A to D (A=excellent, B=good, C=fair, D=unsatisfactory). Please indicate your responses next to each learning objective and return it to us with your completed exam.
Documentation Guidelines for Common Nursing Diagnoses
Once youíve explored your patientís chief complaints, performed an assessment, and analyzed the findings you can formulate your nursing diagnoses (or problem list) and develop a plan of care. This plan will specify patient outcomes and the interventions to achieve them. Completing the process requires documenting your findings and activities.
As an exercise, select at least three particular complaints or situations presented by a patient.
Examples of such situations include:
For a selected complaint or situation, develop a plan of care based on the following documentation:
This exercise is part of your self-study program; you do not need to submit your work and youíll not be graded upon it. All the information you obtain from the health history interview, physical assessment, nursing interventions, and patient response to interventions contributes to the plan of care. Thorough documentation helps you evaluate the plan and revise it as needed.
Table Of Contents
Chapter 1 Documentation Essentials
Chapter 2 Format Comparisons
Chapter 3 Documentation and the Law
Chapter 4 The Acute Hospital
Chapter 5 Long-Term Care Facilities
Chapter 6 Home Health Care Documentation
Chapter 7 Managed Care
Chapter 8 Quality Assurance
"Awesome to do this at home and at my own pace." - M.M., RN, LA
"Excellent documentations." - A.M., LVN, CA
"I would like to see more case examples to illustrate documentation errors." - B.A., RN, OH
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