Get the free Documentation of Nursing Care - University of Michigan Health ... - med umich
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Original Approval: 02/2000 Type: Guideline Revised/Reviewed: 12/2010 Keywords: documentation, flow sheets, medical record, notes, assessment To be reviewed: 12/2013 Supersedes: None Nursing Services
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What is documentation of nursing care?
Documentation of nursing care is the recording of patient assessments, treatments, and outcomes by nurses to ensure quality care and communication.
Who is required to file documentation of nursing care?
All nurses providing care to patients are required to file documentation of nursing care.
How to fill out documentation of nursing care?
Documentation of nursing care should be filled out accurately, promptly, and according to institutional guidelines.
What is the purpose of documentation of nursing care?
The purpose of documentation of nursing care is to track patient progression, ensure continuity of care, and provide legal protection for healthcare providers.
What information must be reported on documentation of nursing care?
Information such as patient vital signs, medication administration, treatments provided, and changes in patient condition must be reported on documentation of nursing care.
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