✔️ 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.
✔️ Identify documentation practices that create legal and professional risks.
✔️ Identify characteristics of nursing documentation that support a legal defense of nursing actions.
✔️ Identify employment and licensure implications of nursing documentation.
✔️ 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 patient’s provider and provider orders, such as questioning orders and receiving verbal orders.
✔️ Identify precautions to observe when using electronic documentation.
