Course Provider
Learning Objectives
State the goals of documentation.
Explain the role of organizational policies and procedures in guiding documentation.
Identify documentation practices that validate safe, effective, and high-quality patient-centered care.
Explain nursing documentation requirements for specific aspects of care, including critical diagnostic results, medications, non-conforming patient behavior, pain, patient and family involvement in care, restraints, and prevention of falls, infections, pressure ulcers, and suicide.
Describe recommended documentation practices concerning communication with the patients provider and provider orders, such as questioning orders and receiving verbal orders.
Identify precautions to observe when using electronic documentation.