Podcast Beta
Questions and Answers
What is an appropriate practice when documenting a patient's condition?
Why is it important to be timely in charting?
What should you do if you find an error in your charting?
Which of the following actions is permissible when documenting?
Signup and view all the answers
Which statement is NOT a guideline for effective documentation?
Signup and view all the answers
What should be avoided in documentation regarding patient information?
Signup and view all the answers
What is a consequence of charting in advance of events?
Signup and view all the answers
What is considered a best practice in documentation?
Signup and view all the answers
Study Notes
Documentation Do's
- Chart changes in a patient's condition and document actions taken to address the changes.
- Review nurses' notes before providing care to identify potential changes in a patient's condition.
- Document care in a timely manner. Late documentation is preferred to no documentation, although accuracy may be compromised with increased time between care and documentation.
- Use precise, objective, and factual descriptions in documentation.
- Correct any errors in documentation according to agency guidelines.
- Ensure correct spelling in all documentation.
- Record any teaching provided to patients.
- Document patients' exact words using quotation marks.
Documentation Don'ts
- Do not chart care in advance of providing it.
- Avoid the use of vague terminology in documentation.
- Do not chart for another person.
- Do not use "patient" instead of the patient's name in documentation.
- Do not alter the medical record, even when requested by a physician.
- Do not document assumptions or subjective opinions that might reflect bias. For example, avoid using terms like "complainer."
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
This quiz covers essential do's and don'ts of nursing documentation, focusing on how to accurately record a patient's condition and the actions taken. Learn the importance of timely, precise, and objective documentation, as well as common pitfalls to avoid. Enhance your awareness of best practices in nursing documentation.
