What should the nurse include in her documentation?

What should the nurse include in her documentation?

Her documentation should include an assessment and interpretation of assessment including: diagnosis (if applicable), • any advice provided to the client and the plan of care (including self-management), and • any follow-up and referral to the RN(NP).

What is narrative documentation in nursing?

Narrative Format. This is the most familiar method of documenting nursing care. ааIt is a diary or story format in chronological order. It is used to document the patient’s status, care, events, treatments, interventions, and patient’s response to the interventions.

What is kardex documentation?

A Kardex is a brand name for an informational filing system that is used as a quick reference for nurses. It’s a desktop file system that gives a brief overview of each patient and is updated every shift. After the patient is discharged, the documents are shredded.

What are do’s and don’ts in documentation?

The Dos & Don’ts of Documentation

• DON’T copy information. Write each transport as if this is the first time you have seen or treated this patient.
• DON’T use vague terms.
• DON’T use P.U.T.S.
• DO support medical necessity.
• DO be specific.
• DO be truthful.
• DO document treatment results.

What are the five C’s in medical record documentation?

Final words: the five “C’s”… Consistent care • Communication • Credibility • Client Centered Care • Charting it all!

How do you write a narrative document in nursing?

10 TIPS FOR WRITING EFFECTIVE NARRATIVE NURSE’S NOTES

1. Be Concise.
2. Note Actions Once They are Completed.
3. When Using Abbreviations, Follow Policy.
4. Follow SOAIP Format.
5. Never Leave White Space.
6. Limit Use of Narrative Nurse’s Notes to Avoid Discrepancies.
7. Document Immediately.
8. Add New Information When Necessary.

What is a narrative document?

A narrative document contains text meant to be read by people rather than machines. Web pages, books, journals, articles, and essays are all narrative documents. These documents have some common traits. Another key feature of narrative documents is specialized element groups, including sections, blocks, and inlines.

What are the 4 components of correct nursing documentation?

Be clear, legible, concise, contemporaneous, progressive and accurate.

What are the four important points of documentation?

The four kinds of documentation are:

• learning-oriented tutorials.
• goal-oriented how-to guides.
• understanding-oriented discussions.
• information-oriented reference material.

What is a nurse kardex?

oxford. views 1,428,169 updated. Kardex (kar-deks) n. originally, the proprietary name for a filing system for nursing records and orders that was held centrally on the ward and contained all the nursing details and observations of patients that had been acquired during their stay in hospital.

What is kardex record?

noun. 1. (medicine) A medical-patient information system which uses forms preprinted on durable card stock; loosely, any similar system for paper-based record-keeping.

Which is the gold standard for nursing documentation?

Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential principles serving as primary guidelines, as outlined in Table 1 (ANA, 2010a). Nurses must also acquire a keen awareness and understanding of their state’s nurse practice act to ensure documentation reflects specific state laws.

What are the Ana principles for nursing documentation?

The ANA’s Principles for Nursing Documentation (ANA, 2010a) expects that high-quality nursing documentation follows regulatory guidelines and mandates across all nursing roles and working settings.

What do you need to know about nursing documentation?

Documentation is a valuable method for demonstrating that the nurse has applied appropriate nursing knowledge, skills, and clinical judgment according to professional nursing standards. Documentation must not only meet professional and employer standards, but it must also meet criteria required by the legal system (Woods, 2019).

What does nursing documentation mean in a court of law?

Nursing documentation is evidence that the patient received proper care. In a court of law, the patient’s health record serves as the legal record of the care provided to that patient to defend against allegations of malpractice, negligence, or failure to meet standards of care (Jacoby & Scruth, 2017).