This independent study is based on the book, Documentation Skills for Quality Patient Care. The book is being used by all levels of nursing education and has been endorsed by at least one State Board of Nursing.
Reviewers report that it is easy to read and understand.
They also say that it covers the subject extremely well. Identify functions that relate to documentation and the components of the nursing process, nursing diagnosis, Nursing Interventions Classification, and Omaha System. Identify the different formats of nursing documentation and their strengths and weaknesses. Use the proper techniques of documentation to meet the patient s clinical and safety needs and all legal requirements, while avoiding the pitfalls of documentation. Identify what needs to be written in summary, evaluative, and progress nursing notes so that they result in complete, concise, and clear notes.