All right. So next let's look at
guidelines for quality documentation.
So if you will look on the side of the
screen that has all of these buzzwords,
these are great things to keep in
mind when you're documenting.
For example, one characteristic is factual documentation.
So if we look at incorrect documentation in this right,
So when we're saying the
patient seems like he's having pain.
Okay, so you can see this is kind of using
that opinion that we talked about earlier.
This is not what we want for documentation.
Now, if you look on the side
that has correct documentation,
we're saying the patient is grimacing
and moaning when his leg is being touched.
So let's look at the difference.
So on the incorrect side, it says "seems".
Again, there's that personal opinion.
When we look at the correct side, as a nurse, we can
see actually, objectively that the patient is grimacing.
We can also use our senses that the patient is moaning.
So these are more tangible data points
to document for legal documentation.
Next, let's look at accurate documentation.
Seems like a no brainer, but here's where we get specific.
So if I said there was a large amount of
drainage, well, that's pretty subjective, right?
What's large to you may not be
large to me, so let's be specific.
Therefore, we would chart something
such as there was 500 mils of drainage.
So see the difference here and that
we have something tangible and specific.
All right, so now let's look at a complete documentation.
So on the incorrect side, we're talking about how
the patient was taught how to check his blood sugar.
Now let's look at the correct side, where it states patient
was able to return demonstrate how to check his blood sugar.
The difference here is on the correct side,
the patient is-- it's already implied basically,
that the patient is able to do their own blood sugar,
but they're returned demonstrating
to the nurse so we can evaluate
if the patient knows how to do the procedure correctly.
Next, let's look at current documentation.
So on our incorrect side, we say that
patient had a temperature at 2:30 AM.
On the correct side, let's compare.
Patient had a temperature of
39.1 degrees Celsius at 2:30 PM.
So on the correct side, we're being
specific and we're documenting the right time.
And lastly, our documentation needs to be organized,
such as when you read your
nurse's note or other documentation,
you should be able to follow it easily.
On the incorrect side, for example, it
states patient had altered mental status,
stomach pain, and could not recall their name.
So if you look at the correct side, we're
gonna group some of this information together
for a more organized pattern such as
the patient had altered mental status,
with the inability to recall his name
and has complaints of stomach pain.