Documentation for Nurses
Evaluation of Individual Objectives
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 you’ve explored your patient’s 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:
- Patient loses a peripheral pulse
- Ineffective breathing pattern
- Chest pain
- Myocardial infarction
- Asthma attack
- Severe pain
- Sleep pattern disturbance
For a selected complaint or situation, develop a plan of care based on the following documentation:
- Document what the patient tells you
- Document what you assess
- Document what you do
- Document what you teach
This exercise is part of your self-study program; you do not need to submit your work and you’ll 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.
After completing this course, you’ll be able to:
- List and elaborate upon the purposes of documentation, specifically continuity of care, reimbursement requirements, regulatory requirements, legal protection and quality of care programs.
- Describe four basic types of forms used to build a clinical record system.
- Identify the disadvantages of a Kardex system.
- Explain in detail three basic form styles: graphic records, flow sheets and standardized forms.
- Enunciate three basic principles of accurate charting (accuracy, brevity, and thoroughness) and outline 16 basic rules for charting.
- Decipher abbreviations and acronyms commonly used in charting.
- Compare and contrast and discuss advantages and disadvantages of various charting forms.
- Discuss documentation and the requirements of the law and point out steps a nurse can take to avoid legal risks.
- List leading causes of malpractice suits against nurses.
- Discuss issues of patient protection, such as informed consent, refusal of treatment, advance directives, privacy and access to records, organ transplantation and abandonment.
- Develop an effective plan of care for your patient by documenting health history, physical assessment, nursing intervention and patient outcomes.
- Document discharge planning information in an acute hospital setting.
- Discuss federal regulations concerning documentation in long-term care facilities.
- Discuss charting formats used in long-term care facilities.
- Describe documentation requirements in the context of home health nursing care.
- Explain the role of documentation in managed care, Medicare and other insurance plans.
- Emphasize the importance of proper documentation in quality assurance.
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