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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Documentation is one of the most critical skills nurses perform, regardless of the setting in which they practice. Accurate, detailed charting provides a clinical picture of the patient and a chronological history of their health care. Nursing documentation enables effective continuity of care for the patient. It also provides legal protection for the nurse and their employer. Nursing documentation provides…
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