Documentation
Characteristics and Education and Training
Characteristics and Education and Training
Training objectives
Global Documentation System
Computer and Hardware Competence
Software Systems Proficiency
Organizational Policies and Procedures has
well-versed in all organizational policies and procedures related to documentation, integrating them into daily nursing practice.
Protection systems should be integrated into both
paper-based and electronic documentation systems
Entries into organization documents or the health record (including but not limited to provider orders) must be:
Accurate, valid, and complete
What are the 3 key components of standardized terminologies?
Planning
Delivery
Evaluation
Nurses' Documentation Training Needs are
Technical Aspects of Documentation and Time and Staffing Considerations
what is the “Downtime” Documentation System
any period during which the EHR system is fully or partially unavailable.
Data Security is?
Ensuring data is safeguarded from unauthorized access.
Authenticated means
that it is truthful, the author is identified, and nothing has been added or inserted
What is standardized terminology's purpose?
it allows for consistent data aggregation and analysis across diverse healthcare settings.
High-quality documentation is
Accurate, relevant, consistent, clear, concise, and complete
Nurses should be
prepared to use the “downtime” system efficiently.
Patient Identification Protection is...
Protecting patient identifiers to prevent misuse.
it must be Dated and time-stamped by who?
the persons who created the entry
What is one benefit of Standardized Terminologies?
Enhances continuity of care.
Facilitates data analysis for quality improvement.
Supports evidence-based practice through clear,
consistent language.
It must be retrievable on a
permanent basis in a nursing-specific manner
it is essential when?
electronic documentation systems are temporarily unavailable.
Confidentiality means?
protecting data or information as it is shared by limiting access to it
it is made by?
using standardized terminology, including acronyms and symbols.
Explain key components of planning
Terms should accurately describe the planning phase of nursing care.
It must also be
Timely, contemporaneous, and sequential
it ensures..
continuity and accuracy in documentation, even during system outages.
Organizational Information Confidentiality is
Protecting the organization’s proprietary and sensitive data.
What does legible and readable mean?
clear enough to read or able to be read or deciphered
Explain the key components of delivery and evaluation
Terminologies should reflect the delivery of care in various environments.
Evaluation terms ensure clear documentation of patient outcomes and care effectiveness.