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Documentation (Nursing)

by Christy Davidson

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    00:00 Welcome back everyone. One of the most important tasks we complete every working day which fosters communication, provides an accurate account of our interactions, and protects us from liability is documentation. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Now there are 2 uses of documentation. One, communication within the healthcare team and also communication with other professionals. So when communicating within the healthcare team, the items that we document include our assessments, clinical problems, communication with other healthcare professionals regarding the patient, communication with and education of the patient, family and the patient's designated support person and other 3rd parties. Or medication records, we also document any order acknowledgements, implementation and management. We document patient clinical parameters such as vital signs, lab values, patient responses and outcomes including changes in the patient's status. And finally, we document plans of care that reflect the social and cultural framework of the patient. When communicating with other professionals, we typically document issues related to credentialing, legal issues, regulation and legislation issues, reimbursement, and research. Now there are 6 documentation principles. First, documentation characteristics. Documentation should be accessible, it should be accurate, relevant and consistent. It should be auditable. It should be clear, concise, and complete, legible, readable and it should also be timely meaning that you document as soon as you can in case others need to access the record. It should also be reflective of the nursing process. Education and training should focus on electronic documentation systems.

    02:07 Third, policies and procedures. Specifically to the organization's preferences in the event of downtime. So for example, if the electronic records go down, how do you document? The protection of systems meaning security and confidentiality of your patient's information. Documentation entries. They should be authenticated. That means that the information is truthful, the author is identified and nothing has been added or inserted. It should also be dated and timestamped by the person who created the entry. And finally, you should use standardized terminologies because date could be aggregated and analyzed and also be sure to include the terms that are used to describe the planning, delivery, and evaluation of the nursing care of the patient or client in diverse settings. So here is an example. Cindy is a nurse manager on a busy medical surgical unit. The Joint Commission is interviewing her staff during a site visit and asked to review several charts of currently admitted patients. What type of communication with other professionals does this review of documentation demonstrate? Is it credentialing, legal, regulation and legislation, reimbursement, or research? If you selected credentialing, you are correct. The Joint Commission is considered a credentialing agency responsible for ensuring quality care is provided at the facility.

    03:37 So remember, nursing documentation provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. So what do we learn today? We've learned documentation of nurse's work is critical for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payers, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with healthcare. Documentation provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care.

    04:29 And finally, documentation is sometimes viewed as burdensome and even a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and all settings. I hope you've enjoyed today's video on Documentation. Thank you so much for watching.


    About the Lecture

    The lecture Documentation (Nursing) by Christy Davidson is from the course Leadership and Management (Nursing).


    Included Quiz Questions

    1. Change in client status
    2. Medical treatment decisions
    3. Insurance coverage information
    4. Physical therapy exercise plan
    1. Documentation
    2. Medication administration record
    3. Protected health information
    4. Patient plan of care
    1. Reimbursement
    2. Legal
    3. Credentialing
    4. Regulation and legislation

    Author of lecture Documentation (Nursing)

     Christy Davidson

    Christy Davidson


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