Question

IN THE KNOW A Communications Skis Module: Reporting&Documenting Clent Care REPORTING & DOCUMENTING 1. As a nursing assistant you are responsible for reporting and Documenting information about your clients. Tor F 2. Clinical documentation is important because it: a. Serve as a legal evidence that you have perform Your job b. Helps meet the requirements for licensure and for Accreditation. c. Keep a record of services provided. d. All the above 3. List 2 things you should include in your charting. 1. 2. 4. List the 5 rules of documentation. 1. 2. 3.

Answer 1

1. As a nurse assistant we are responsible for reporting and documentation of information about the client.

Nurse is the primary health care provider. She is responsible for coordinating and collaboration of care. Documentation is also her prime responsibility which can be done by keeping records and reports accurate.

2.Answer is all of the above.  

Document servers as a legal evidence and it is important to fulfill the accreditation and licensure of the institutions. It is very important for the quality analysis and it can act as a checklist for the services provided.

3.

1. Factual

Document should contain facts about the concept. The data should be relevant.

2. Clarity and brevity

The data recorded should be clear and brief

3. Legibility

The record should be written legibily and should be with proper handwriting, explanation.

4. Sequential

The data should be written in the order and should be numbered

5. Accuracy

The data should be correct and written in the same time of the incident. It should be signed with proper date and time.