What's the Purpose
Used to provide information about the patient across the continuum of care
What is the communication component of documentation
Performed in an attempt to break the cycle associated with substance abuse
What is the OUD screening
Failure to complete nursing assessments or adequately monitor patients are leading causes of this
What are malpractice allegations
Includes what the patient says and nurse observations
What is objective and subjective information
The chief complaint, and assessment of the ABCDs and body system involved in the chief complaint are all components of this
What is the focused assessment
Contains information like vital signs, interventions, changes in clinical status
What is the patient record
Completed using the ASQ tool
What is pediatric psych screening
These hospital units are at highest risk of malpractice claims
What are the ED, ICU, and PACU
Accomplished using phrases and checklists
What is consistent documentation
Use this feature to enter a previous time in a flowsheet
What is insert column
Supports or disputes complaints and accusations of malpractice and negligence
What is the legal component of documentation
Completed on all patients who present to the ED, when there is a change in a patient's clinical condition, and with each handoff
What is fall risk screening
Where to find information about nursing standards of practice
What is the American Nurses Association (ANA) website
Includes signs, symptoms, and pertinent negatives
What is relevant information
Advantages for using this method of documentation include they are prepopulated, they serve as a visual que for what needs to be documented, and they reduce documentation time
What are flowsheets
Getting credit for work is part of this component of nursing documentation
What is reflection of nursing practice standards
Includes an MD quick evaluation within 10-minutes of arrival
What is BEFAST
Duty to act, breach of duty, causation, and damages (injury)
What are the four elements needed to prove negligence
Errors can be prevented when documentation in completed in this manner
What is timely
A handoff note, vital signs, PAWS screening, and the disposition of personal belongings are required for this
What is admission or transfer
Used to validate use of policies and procedures, and if evidence-based practices are being followed
What is a documentation audit
Completed on all patients 18 years of age and older who present to the ED, when labs are resulted, and/or when there is a change in a patient's clinical condition
What is sepsis screening
When a patient's clinical condition is clearly documented, this demonstrates the nurse did this
What is painted a picture
This information should be reviewed on every patient (especially ESI 1, 2, 3)
What are medical history and medications