http://youstudynursing.com/ The purpose of this video is to outline the importance of documentation in nursing to help you prepare for nursing exams and the Jurisprudence exam. Nursing responsibilities for documentation will also be clarified. In a subsequent video the DEAR method of focus charting will be discussed. (See http://youtu.be/7aWYp4cXBV0)
Documentation is a critical part of client care that is needed to monitor client well being and communicate care that has been provided. It is accessed by the healthcare team during care and in the event of any investigations.
Regardless of the form of documentation, the nursing standards in the area where you are practicing must be met.
There are many reasons that clear, accurate documentation is essential for quality nursing care. Complete and accurate documentation facilitates client care, professionalism, growth and advances in practice.
Nurses are legally accountable to ensure that their documentation meets the practice standards of their governing body. Documentation is used in the event of legal proceedings and/or college investigations. If it is not documented it was not done. Improper documentation has been the cause of errors in the healthcare setting that have led to adverse patent reactions and even death. It is very important to make sure you document properly.
Failure to meet the ethical or practice standards of the profession through actions or omissions is considered professional misconduct under the Nursing Act. Examples that relate to documentation include not documenting care, inaccurate documentation and knowingly creating or signing inaccurate records.
For more detailed information please review your college’s standards on documentation and professional misconduct as well as the nursing act.
The College of Nurses of Ontario outlines statements and indicators in relation to communication, accountability and security of documentation.
Nurses are accountable for accurate, clear and comprehensive communication of data including assessment of client needs, nursing actions and the client’s outcome.
Documentation must be complete, accurate and completed within a reasonable time frame.
Captured health information must be maintained in confidence and securely stored and/or destroyed in congruence with practice standards, organizational policies and legislative requirements.
For more detailed information and indicators of meeting your expectations please review the college’s documentation standard.
There are many ways to document data that meet these practice standards. The type you will use will depend on your work setting. Some activity will be recorded on a flow sheet. Nursing notes are also an important part of the health care record. For more study resources please visit youstudynursing.com
You are also encouraged to visit the College of Nurses of Ontario’s Website and complete the learning module for documentation. It comes complete with a quiz at the end of the module.
For more information on DEAR charting please see part 2 of this video. If you want more detailed videos on documentation just ask.
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