Careplanning:
Documentation, Directions,
and Teaching | Nursing
Study Guide
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documentation written or electronic legal record of all pertinent interactions with the
patient
what does documentation include data related to assessing, diagnosing, planning, implementing, and
evaluating
what does documentation facilitate? quality, evidenced-based patient care
what does documentation serve as? a financial and legal record
what does documentation help and support? clinical research and supports decision analysis
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