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2016 4.6 Satisfied (33 Votes)
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Be clear, legible, concise, contemporaneous, progressive and accurate.
Documenting at the patients home will enable clinicians to record medication, treatment, and care plan changes during the visit/shift. These changes will immediately be available for the next visit for the next clinician to administer the right medication and treatment.
There are five primary guidelines that ensure efficient quality documentation. They include; keeping the documentation factual, accurate, current, organized, and complete. When using factual information, use descriptive, objective information, and support patient statements with objective data.
The nursing documents should be: Accessible. Accurate. Relevant. Auditable. Clear, concise, comprehensive, and thoughtful. Legible/readable. Aligned with the nursing process. Retrievable permanently.
There are five primary guidelines that ensure efficient quality documentation. They include; keeping the documentation factual, accurate, current, organized, and complete.
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