What Is Good Nursing Documentation?

What is proper documentation?

Proper documentation provides evidence of what has transpired as well as provides information for researching discrepancies.

Supporting documentation may come in paper or electronic form.

In recent years, more often, official supporting documentation has moved from paper based to electronic forms..

What is meant by documentation?

Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. Documentation can be provided on paper, online, or on digital or analog media, such as audio tape or CDs.

What are five characteristics of good medical documentation?

What Are Five Characteristics Of Good Medical Documentation? Medical CommunicationsAccuracy In Medical Communications. One of the most important characteristics of good medical communications is the level of accuracy. … Accessibility of the record. … Comprehensiveness. … Consistency In Medical Communications. … Updated information.

What is the purpose of nursing documentation?

In nursing research, documentation is used to assess nursing interventions and evaluate client outcomes, identify care and documentation issues and advance evidence-based practice. Nurses are required to make and keep records of their professional practice.

What are 3 types of documents?

Common Types of DocumentsEmails.Business Letters.Business Reports.Transactional Documents.Financial Reports and Documents.

What are the 4 main ethical principles in nursing?

Nurses are advocates for patients and must find a balance while delivering patient care. There are four main principles of ethics: autonomy, beneficence, justice, and non-maleficence. Each patient has the right to make their own decisions based on their own beliefs and values.

What does charting mean in nursing?

Charting in nursing provides a documented medical record of services provided during a patient’s care, including procedures performed, medications administered, diagnostic test results and interactions between the patient and healthcare professionals.

What is another name for documentation?

attestationauthentication.corroboration.declaration.documentation.evidence.proof.substantiation.testament.More items…

What is effective documentation 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.

What are the types of documentation?

Types of documentation include:Requirements – Statements that identify attributes, capabilities, characteristics, or qualities of a system. … Architecture/Design – Overview of software. … Technical – Documentation of code, algorithms, interfaces, and APIs.More items…

Why is correct documentation important?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider. … Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care.

How do you write a patient report?

Summary. The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

How do you write a good nursing report?

How to Write a Nursing Report?State your position clearly.Write the reason why you are creating a report.Provide an example or at least two to show your position.Support your decision with statistics and facts.As much as possible, keep your report short and concise.More items…

How do you write a nursing patient note?

Nursing documentation: How to write a patient’s notesEnsure your writing is clear and legible. Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the right medication. … Note all communication. … Write as often as you can. … Try the PIE format. … Know what sort of things to record.

What are the characteristics of good documentation?

Characteristics of Good DocumentationGood Documentation is Up to Date.Good Documentation anticipates failure. … Good Documentation does not contain specific terms without clear definitions. … Good Documentation does not use words like “simply”. … Good Documentation is extensive, and has many examples. … Good Documentation has occasional pictures or even humor.