MEDICAL

Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred.

Nurses may document information pertaining to individual clients or groups of clients.

Individual Clients
When caring for an individual client (which may include the client’s family), the nurse’s documentation provides a clear picture of the status of the client, the actions of the nurse, and the client outcomes.

Nursing documentation clearly describes:
an assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; a care plan or health plan reflecting the needs and goals of the client; needed changes to the care plan; information reported to a physician or other health care provider and, when appropriate, that provider’s response; and advocacy undertaken by the nurse on behalf of the client.

Groups of Clients
When providing service to groups of clients (e.g., therapy groups, public health programs), service records (or an equivalent) are used to document the service provided and overall observations pertaining to the group. Similar to documentation for individuals, documentation for groups reflects the needs assessment, plans, actions taken, and evaluation of the group outcomes.

Documentation of services provided to a group of clients describes:
the purpose and goal of the group; the criteria for participation; intervention activities and group processes; and an evaluation of group outcomes.

Pertinent information about individual clients within the group is documented on individual client health records, not on the group service record. When charting on an individual client health record, names of other group members are not identified.

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Tags: Journal of Clinical Nursing | Legislation Relevant to Nurses’ Practice | Nursing documentation standards | Professional Standards for Registered Nurses and Nurse Practitioners | Self-employed Nurse | Telehealth | Telenursing

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<h2>Nursing Documentation</h2> <p style="text-align: justify;">Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred.</p> <p style="text-align: justify;">Nurses may document information pertaining to individual clients or groups of clients.</p> <p style="text-align: justify;">Individual Clients<br /> When caring for an individual client (which may include the client’s family), the <a title="nurse" href="http://911medicalcare.com/healthcare/nurse/">nurse</a>’s documentation provides a clear picture of the status of the client, the actions of the nurse, and the client outcomes.</p> <p style="text-align: justify;"><a title="Nursing" href="http://911medicalcare.com/medicalcare/nursing/">Nursing</a> documentation clearly describes:<br /> an assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; a care plan or health plan reflecting the needs and goals of the client; needed changes to the care plan; information reported to a <a title="physician" href="http://911medicalcare.com/medicalcare/physician/">physician</a> or other health care provider and, when appropriate, that provider’s response; and advocacy undertaken by the nurse on behalf of the client.</p> <p style="text-align: justify;">Groups of Clients<br /> When providing service to groups of clients (e.g., therapy groups, public health programs), service records (or an equivalent) are used to document the service provided and overall observations pertaining to the group. Similar to documentation for individuals, documentation for groups reflects the needs assessment, plans, actions taken, and evaluation of the group outcomes.</p> <p style="text-align: justify;">Documentation of services provided to a group of clients describes:<br /> the purpose and goal of the group; the criteria for participation; intervention activities and group processes; and an evaluation of group outcomes.</p> <p style="text-align: justify;">Pertinent information about individual clients within the group is documented on individual client health records, not on the group service record. When charting on an individual client health record, names of other group members are not identified.</p> <p style="text-align: justify;">(Read More on Free Ebook at PDF Format)</p> <p style="text-align: justify;"><a href="http://911medicalcare.com/pdf/nursing-documentation" target="_blank">Download</a> Nursing Documentation.pdf</p><br/><a href="http://www.socialmarker.com/?link=http://911medicalcare.com/nurse/nursing-documentation/&title=Nursing+Documentation&text=...&tags=" target="_blank"><img src= "http://www.socialmarker.com/bookmark.gif" border="0" /></a><noscript><a href="http://www.socialmarker.com" >Social Bookmarking</a></noscript> <p>The article <a href="http://911medicalcare.com/nurse/nursing-documentation/">Nursing Documentation</a> is provided by <a href="http://911medicalcare.com" title="Manual Nurse and health Guidelines"> Manual Nurse and Health Guidelines</a>. The article from<a href="http://911medicalcare.com" title="Medical"> Medical</a> site is freely distributed for non-commercial purposes to include the source for the article and does not alter the content.</p>

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