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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett
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Chapter 20: Documenting and Reporting

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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett | Registered Nurse (RN) School Study Aid

Chapter 20: Documenting and Reporting
3 Picmonics to Learn | 7 mins
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
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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
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2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
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1 min

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