What are the types of nursing documentation?

The most common types of nursing documentation include the following:

  • Nursing Progress Notes.
  • Narrative Nursing Notes.
  • Problem-Oriented Nursing Notes.
  • Charting By Exception Nursing Notes.
  • Nursing Admission Assessment.
  • Nursing Care Plans.
  • Graphic Sheets.
  • Medication Administration Records (MARs)

What is falsification of documents?

Document falsification is a serious matter. Forging a signature comes under this category as does the act of altering, concealing or destroying records. Trying to alter the facts. The act of altering records is an example of document falsification, which is a white-collar crime.

What is good nursing documentation?

The nursing record should include assessment, planning, implementation, and evaluation of care. Ensure the record begins with an identification sheet. This contains the patient’s personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.

Where are Ana’s principles for nursing documentation located?

ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings. American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA www.Nursingworld.org

What kind of documentation is required for nursing?

State nursing practice acts may vary somewhat, but all establish guidelines for documentation and accountability. Additionally accreditation agencies, such as the Joint Commission, require individualized plans of care for clients and have standards for documentation. Nursing process

Why is documentation so important in the RCH?

Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.

Is the book improving nursing documentation and reducing risk?

Improving Nursing Documentation and Reducing Risk is published by HCPro, a division of BLR. Copyright © 2016 HCPro, a division of BLR All rights reserved. Printed in the United States of America.

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