documentation

Documenting Respiratory, Cardiovascular and Neurological Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. …

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Documenting Communication and Cognitive Function

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient …

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Problematic Areas Where Gaps in Documentation Occur

Abnormal vital signs. A significant deviation from what is considered to the patient’s normal requires an entry detailing what is being done about it. For example, deviations may be fever, elevated BP, or slow respiratory rate. If your response is to monitor the patient more closely, then write that in the medical record followed by …

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The Medical Record: Your Best Defense – 2

Your entries in the medical record are recognized as the evidence of adherence to or deviation from a standard of care provided to a patient. The practice of nursing has become more complex, with the higher acuity, shorter length of stay, electronic medical records, and the increased regulatory compliance requirements including the meaningful use criteria …

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