Chapter Objectives: At the end of this chapter, the learner will:

1) document assessment findings using best practice standards

2) recognize variations in documentation of assessment findings ( paper. electronic)

3) evaluate legal implications of accurate and concise documentation in nursing practice.

Overview of Documentation of Assessment Findings

The nurse needs to document significant events and information in any patient’s on-going care from assessment, planning, intervention and evaluation. Documentation facilitates safety and quality care in so many ways, one of which is the continuity of care from one practitioner to the other. There are also ethical, legal and financial implications of correct and accurate documentation.

The concept of accurate documentation was discussed previously in Chapter 2 of this guide, but it is worthwhile to review it once more at the end of this guide to health assessment for nurses.

Guide to Documentation

https://pressbooks.library.ryerson.ca/documentation/

Review the information through the link below: ( note: the word resident refers to patients )

Guide to documentation for Nurses

In today’s health care environment, all the information in the prior guide must also be applied to electronic health records management. The following video by the Oncology Nursing Society discusses the value of electronic health records:

https://www.youtube.com/watch?v=3XfEoB76iT4

Citations and Attributions