NURS2106 TEST QUESTIONS AND ANSWERS A+
GRADED .Buy Quality Materials!
Documentation
Anything written or electronically generated that describes the status of a patient or the
care given to that client
(Health record, client record, Charts)
Purpose of documentation
- Communication/Care planning
- Funding and resource management
- Auditing and monitoring
- Research
- Education
- Legal responsibility
6 Important characteristics for quality documentation
- Factual
- Accurate
- Complete
- Current
- Organized
- Comply with standards
While documenting, the nurse MUST remember that they are...?
Accountable and responsible for their actions
What are nurses required to chart/document
- Assessment date
- Nursing interventions, treatments & evaluation
- Medication Administration
- Changes in condition, physical, mental, emotional (worse or improved)
- Finding outside of previous baseline of client
- Patients/family teachings
- Discharge planning
- Leaving the unit/ward for tests, day passes, family visits
Methods of Documentations - Narrative
Story-like format to document information
Methods of Documentations - Problem Oriented
Primary focus on patients' individual problems
Methods of Documentations - Source Charting
Each discipline (ex: nursing, social work, physiotherapist) has a separate section to
record data.
Methods of Documentations - Charting by Exception
Clients meets all standards unless otherwise documented
Common format of nursing notes
SOAP - Subjective data, Objective data, Assessment, Plan
PIE - Problem, Intervention, Evaluation
GRADED .Buy Quality Materials!
Documentation
Anything written or electronically generated that describes the status of a patient or the
care given to that client
(Health record, client record, Charts)
Purpose of documentation
- Communication/Care planning
- Funding and resource management
- Auditing and monitoring
- Research
- Education
- Legal responsibility
6 Important characteristics for quality documentation
- Factual
- Accurate
- Complete
- Current
- Organized
- Comply with standards
While documenting, the nurse MUST remember that they are...?
Accountable and responsible for their actions
What are nurses required to chart/document
- Assessment date
- Nursing interventions, treatments & evaluation
- Medication Administration
- Changes in condition, physical, mental, emotional (worse or improved)
- Finding outside of previous baseline of client
- Patients/family teachings
- Discharge planning
- Leaving the unit/ward for tests, day passes, family visits
Methods of Documentations - Narrative
Story-like format to document information
Methods of Documentations - Problem Oriented
Primary focus on patients' individual problems
Methods of Documentations - Source Charting
Each discipline (ex: nursing, social work, physiotherapist) has a separate section to
record data.
Methods of Documentations - Charting by Exception
Clients meets all standards unless otherwise documented
Common format of nursing notes
SOAP - Subjective data, Objective data, Assessment, Plan
PIE - Problem, Intervention, Evaluation
