Documentation Basic
The documentation immediately after providing patient care?
What care was provided, and the patient's response.
Before documenting any care, this must be verified to ensure information is entered into the correct chart.
What is the correct patient?
To maintain an accurate medication record, this should occur immediately after a medication is given.
What is documenting medication administration?
After completing a patient assessment, this should be done to ensure the patient's record remains current.
What is documenting the assessment finding?
This mistake occurs when information is entered into another patient's chart instead of the intended record.
What is documenting on the wrong patient chart?
This makes documentation essential for patient safety, team communication, and legal compliance
What is accurate documentation?
These two pieces of information are commonly used to confirm a patient's identity before providing care.
What is the patient's name and date of birth?
This abbreviation indicates that a medication is administered only when needed by the patient.
What is PRN?
When a patient reports new pain, this information should be documented along with any interventions provided.
What are the patient's symptoms and response to treatment?
Leaving out important details from a patient's record is an example of this common documentation problem.
What is incomplete documentation?
When a documentation mistake occurs, this action should be taken instead of deleting the original entry.
What is the following organizational policy to correct the error?
Documenting this information helps prevent medication and treatment errors.
What are patient allergies?
Even when a patient chooses not to take a medication, this action is still required.
What is documenting the medication refusal?
Before a patient leaves the facility, this information should be documented regarding instructions, education, and disposition.
What is discharge documentation?
This documentation practice can create inaccurate or outdated patient information when used improperly.
What is copy-and-paste documentation?
This serves as the official record of a patient's treatment, care, and clinical history.
What is the patient's medical record?
After a patient fall, this information should be recorded, including assessments, interventions, and notifications.
What is the fall event and the care provided afterward?
When documenting a medication administration, these details should be recorded: medication, dose, route, and this element.
What is the time of the administrations?
When receiving a verbal order from a provider, this should be done according to organizational policy.
What is doumenting a verifying the verbal order?
When documentation is postponed until much later, this important risk increases.
What is forgetting or omitting important details?
This documentation practice emphasizes accuracy, objectivity, and timeliness.
What is proper charting/documentation
These results should be documented and communicated immediately to support timely patient care.
What are critical results?
This safety process compares a patient's current medications to ensure accuracy and prevent errors.
What is medication reconciliation?
If a patient's condition suddenly changes, these actions should be documented to support continuity of care.
What are the assessment findings, interventions, provider notification, and patient response?
This best practice helps reduce documentation mistakes and improve record accuracy.
What is documenting accurately, promptly, and reviewing entries before submission?