Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Nursing Care Processes
Lecture:Nursing routines and procedures including performing invasive procedures, administering medication, documenting procedures, and using technology
Slide content:Documentation Procedures Nurses must document every step of the nursing process: Patient information: Symptoms, observations, medications, treatments, patient response Contact with other health care providers: When primary care provider saw chart or patient, appointments, consultations Nurses actions: What the nurse did for the patient 16
Slide notes:Good documentation of patient care is vital because it makes it easier to provide consistent care across health care providers and shifts. Third-party payers also expect accurate documentation in order to reimburse health care providers for the cost of care. Furthermore, the patient record is an important legal document. Every step of the nursing process needs to be documented and updated in a timely way for each patient. The nurse must record the patients symptoms and the nurses observations and any new symptoms or problems that occur while the nurse cares for the patient. The patients response to medications and other treatments also must be recorded by the nurse. If the patient is hospitalized, the nurse also needs to record any information received from the patients primary care provider and note any time the provider sees the patient or reviews the patients chart. The nurse should also record the details of any consultation about the patient. The nurse must record what he or she does for the patient; however, the nurse should not record what other health care providers do for the patient unless the nurse notes the name of the provider. 16