Order Documentation and the Nurse Assignment

Order Documentation and the Nurse Assignment
1. List five reasons for documentation.
2. What is “effective” documentation?
3. Discuss the continuous quality improvement (CQI) method.
4. Discuss important aspects of the incident, variance, or occurrence report
and what should be included in a report.
5. Outline and discuss 10 charting tips.
6. Discuss current charting systems available to the nurse.
7. Discuss the advantages and disadvantages of each charting system.
8. Outline important points that should be remembered when dealing with a
DNR order.
9. Relate ethical and legal issues involved with electronic charting.
10. Discuss what must be documented with a patient who leaves a facility
against medical advice (AMA).
11. Relate three areas in nursing of potential danger and legal exposure when
documenting.
12. Discuss an ethical issue involving documentation.
13. Discuss the possible legal, ethical, and disciplinary implications of false
documentation.
14. Outline the documentation/charting policies in your institution.
15. Discuss if precharting is allowed in your state. Why or why not? Define your
state board’s position on precharting.
Order Documentation and the Nurse Assignment
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