8 Documentation and Continuity of Care Free Online FlashCards

What makes nursing documentation objective?

Record what you observed, measured, did, or were told, and distinguish a patient's own words from your interpretation.

What makes a health record entry attributable?

Use your own authorized login or signature, and document only care you provided or observed.

Why should care be documented promptly?

Document close to the time care occurs, following policy, so clinicians can make decisions using current information.

What makes documentation relevant and complete?

Include the information needed to understand the situation and care, such as assessment findings, interventions, response, notifications, and the plan.

How should an error in a health record be corrected?

Follow the approved correction process so the original entry is preserved and the correction or addendum is visible; never delete, obscure, or backdate an entry to conceal an error.

How do documentation and reporting differ?

Documentation creates a record; reporting communicates information to someone who may need to act.

What should you do about an urgent patient change?

Promptly notify the appropriate clinician using the organization's communication and escalation procedures; do not rely on a chart entry alone.

What do the letters in SBAR represent?

Situation, Background, Assessment, and Recommendation or request.

What is a clinical handoff?

A handoff transfers information and responsibility between clinicians, shifts, units, or care settings.

What key information should a handoff include?

Identify the patient, summarize current status and relevant background, highlight safety risks, list pending tasks and timing, and explain changes that require reassessment or escalation.

What should the receiving clinician do during a handoff?

The receiving clinician should have the opportunity to ask questions and confirm the plan.

What are the components of the I-PASS handoff framework?

Illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by the receiver.