NURS 221 Liberty University - Question and answers rated A+ 2024/2025 NURS 221 - Communication, Documentation and Reporting
documentation - correct answer - is any written or electronically generated information about a client that describes the care or services provided to that client ... a...
NURS 221 - Communication,
Documentation and Reporting
documentation - correct answer ✔- is any written or electronically generated
information about a client that describes the care or services provided to that
client ... an essential part of nursing practice
documentation: key point - correct answer ✔- outlines the clients plan of
care, interventions, and health services provided
- promotes effective communication and safety
- provides informational continuity of care
- serves as a record of critical thinking and judgement
- describes the quality of care and standard of practice
- minimizes risk of errors if done effectively and accurately
- is a legal document that provides evidence of the care provided
types of records - correct answer ✔- database (assessment information)
- problem list
- care plans
- progress notes (ex: narrative records)
- care maps / critical pathways
- flow sheets, graphic records
- kardex
- electronic health records
standards for documentation - correct answer ✔1: accountability
2: communication and safe provision of care
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