What should be in your documentation? ❖ Nursing documentation should contain the following: ➢ All aspects of the nursing process. ➢ Plan of care. |
The following table provides examples of how nursing can document resident status related to occupational therapy. MDS Section to Review MDS Title/Functional. |
First, select an example of your 'everyday' nursing documentation. There are several ways you can do this. You may wish to think back over your last day at work ... |
For example, use of supporting documentation on other facility worksheets or forms. Section I: The Medical Record. Item I-29: Omissions in documentation. Item ... |
The main parts of this system are an integrated plan of care, assessment flow sheets, and nurse's progress notes. 5. Focus charting: System using a column ... |
Assessment: The nurse states their professional, objective opinion considering the current situation and background. Recommendation: Recommend an action plan ... |
Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. |
Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation ... |
Vague or opinionated documentation can interfere with continuity of care and misrepresent your assessment findings. Here are examples of notes from a client's ... |
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