NUR115 - Nursing Documentation (1.5 HR)

Author: M. Nicole Jolley MSN, BSN, RN

Correct, proper, accurate, and timely documentation is one of the most important things for nurses in any capacity. It is often said, “If it wasn’t charted, it wasn’t done.” While that is true, charting tasks without doing them is also considered not done. Documenting appropriately proves you provided quality care and met nursing standards. Many times, it is also how facilities are reimbursed which ultimately affects how nursing staff are paid. Documentation is how we communicate with other members of the health care team, other entities, as well as the patients and their families. Correct and proper documentation is how nurses provide consistent, appropriate care and protects both our patients and us.

Objectives

Upon completion of this course, you will be able to:

1. Define correct and proper documentation.
2. List at least five purposes of documentation.
3. List several protocols and scenarios for different types of documentation.
4. List the types of documentation.
5. Discuss legal aspects of documentation.