Main Text Show Nurses have a legal obligation to document. In Ontario, you must adhere to the practice standard titled Documentation, Revised 2008 (College of Nurses of Ontario, 2019a). This standard will be discussed in more detail later; for now, Table 1 lists some fundamental reasons why documentation is so important. Table 1: Why documentation is so important
Documentation and Violence Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings. Therefore, as a nurse you must clearly and comprehensively document your detailed assessment. It is important that you incorporate direct quotes from the client and place them in quotation marks, even if they are expletives involving profanity and obscenity. Photographic images are also necessary to document cases of physical and sexual violence. In cases of bruising, swelling, lacerations, and/or contusions, use a measurement tool as a point of reference. Consult your institutional policies about photography and record keeping, including guidelines related to designated devices for recording images and how the client is identified in the picture. Activity: Check Your UnderstandingWhat are the three C's of accurate documentation?3 C's of Accurate Documentation. Be Clear. The first step in any problem solving is identifying the problem and writing it down as a problem statement. ... . Be Concise. Note-taking while listening and speaking to someone on the phone may mean writing in phrases. ... . Be Complete.. What is the purpose of documentation?Documentation is a great tool in protecting against lawsuits and complaints. Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations.
Which elements of documentation can be delegated to unlicensed assistive personnel?Which elements of documentation can be delegated to unlicensed assistive personnel? 3. Documentation of vital signs and activities of daily living (ADLs).. Assessment findings.. Nursing diagnosis.. Plan of care.. Evaluation.. Who owns the information that is written about him or her on a client health record?The facility or agency owns the client's health record; however the client owns the information in it. 3.
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