Documentation

Effective documentation practices include:

1. Using clear, concise, and ____ language meaning it is not open to interpretaion.

2. Ensure documentation is ____ and sequential

3. Use approved ______ and symbols. You can review the ____ approved list. 

4. Maintain ____ and completeness

objective; timely; abbreviation; facility; accuracy

To protect patient’s confidentiality:

1. Adhere to _____ regulation

2. Limit access to patient records to _____ personnel.

3. Avoid discussing patient info in ____ areas.

4. Use ___ methods for electronic documentation.

Protecting patient confidentiality is a legal and ____ obligation of nurses.

HIPAA; authorized; public; secure; ethical

Purpose for accurate documentation includes:

1. It serves as a ___ ___ of the care provided.

2. It facilitates _____ among healthcare team members.

3. It supports _____ and reimbursement processes

4. It contributes to _____ ______ and research.

legal record; communication; billling; quality improvement

Documentation can be used in legal _____ so it is critical to record info ________ and accurately to uphold ethical standards and to ____ yourself.

proceedings; truthfully; protect

You want to document all aspects of patient care which includes the ____, interventions, and any ___ in the patient’s condition. This provides a ____ record that support continuity of care. 

You should document all treatments and the ___ they were given. You need to document if the treatment was well _____ by the patient or not because it will show if the patient was stable. You need to document any _______ (shorthand) administration and any patient ____ provided.

assessment; changes; comprehensive; times; tolerated; med; education

The EHR hae benefits which include improving ____, reducing ____, and enhancing ____ amoing the healthcare team. 

There are also some challenges including learning ____, ____ issues like if the power goes out, and issues with ____ like there is a chance of being hacked. 

accessibility; errors; coordination; curve; technical; security

To avoid documentation errors you can:

1. ____ check entries for accuracy

2. Avoid ___ entries and if needed label accurately. 

3. Correct errors by drawing a ____ line through the error, and then initial and ____ it. 

4. Never alter or _____ documentation. 

double; late; single; date; falsify

Formats for nursing documentation include:

1. Nursing ____ forms for initial/ongoing assessments

2. Nursing ___ ____ which are individualized patient care strategies. 

3. ____- notes which are narrative and SOAP notes detailing progress

4. _____ sheets which track routine care and ____ signs.

5. Medication Administration ____ which log the meds given. 

6. The ____ summaries which outline patient status and instructions upong discharge. 

assessment; care plans; progress; flow; vital; record; discharge