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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett/
Chapter 20: Documenting and ReportingDocumentation and Reporting - Fundamentals of Nursing
Picmonic helps you not just memorize, but truly understand the importance of clear and concise documentation in nursing. You'll learn best practices for accurate reporting, ensuring smooth communication with the healthcare team and ultimately, better patient care. Become a confident nurse who excels in documentation with Picmonic by your side!
Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett | Registered Nurse (RN) School Study Aid
Documentation Guidelines
- Factual
- Objective Information
- Subjective Information from Patient
- Objective Supports Subjective
- Accurate
- Avoid Unnecessary Words and Details
- Exact Measurements
- Current
- Assessments
- Document ASAP
- Treatment and Response
- Change in Status
- Admission, Transfer, Discharge or Death
- Organized
- Document in a Logical Order
- Ensure Information Recorded is Complete
4 mins
Reports
- Reporting
- Shared Communication
- ISBAR
- ISBAR
- Identify
- Situation
- Background
- Assessment
- Recommendation
- Types of Reports
- Change-of-Shift/Handoff Reports
- Telephone/Telemedicine Reports
- Transfer and Discharge Reports
2 mins
I-SBAR-R
- Identify
- Situation
- Background
- Assessment
- Recommendation
- Readback
1 min
