In this post, we continue our discussion of documentation with methods of documentation. Methods of Documentation: Narrative Note In narrative documentation, a summary of the care provided is written in paragraph form. The patient’s status should be described in detail, as well as all treatments and nursing interventions performed and the patient’s response to those interventions. Narrative notes may often…
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ELEMENTS OF GOOD DOCUMENTATION In our last post, we discussed nine Elements of Good Documentation. This week, we continue our discussion. Document what the patient tells you with exact quotes Using exactly what the patient tells you in quotation marks provides an indication of the patient’s mental status and their ability to comprehend what is going on, and it is…
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ELEMENTS OF GOOD DOCUMENTATION Write legibly Since the patient’s health record is the main method by which information about the patient is conveyed to all members of the healthcare team, it is vitally important that all notes can be read by all caregivers. Errors may be made if the record cannot be read. Lawyers have been known to infer that…
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