What are the principles of effective documentation in nursing care?
Principles of Nursing Documentation
- Principles of Documentation.
- Date and Time.
- Correct Spelling.
- Appropriateness.
- Legal Protection.
- Accuracy.
- Completeness.
- Brief.
What is a nursing documentation system?
Nursing documentation mainly consists of a client’s background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client’s data captured at the relevant stages of the nursing process.
Why is standardized documentation important in nursing?
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
When does documentation need to be completed in nursing?
On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the National Safety & Quality Health Service Standards. There is an expectation that shift required documentation is completed within 3 hours of shift start time.
What makes a legal document in nursing care?
Therefore, documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care.
Is the standard of care of a nurse legally binding?
Specialty guidelines for practice aren’t legally binding, but they do create a standard of care for a patient in a particular setting. This standard of care can be used to establish what the nurse’s duty should’ve been in a situation for which litigation occurs.
What are state laws that relate to nursing?
State laws that are specific to nursing practice are typically called nursing practice acts and associated rules and regulations. 2 The objective of any state’s nursing practice act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the healthcare team.