Documentation

Definition

Documentation is the accurate and complete recording of patient care, including medication administration, in medical records. It ensures continuity of care, legal compliance, and serves as a communication tool among healthcare providers.

5 Must Know Facts For Your Next Test

1. Accurate documentation is legally required to protect both patients and healthcare providers.
2. Incomplete or incorrect documentation can result in medication errors and adverse patient outcomes.
3. Documentation must be done promptly after administering medications to ensure up-to-date records.
4. Electronic Health Records (EHR) systems are commonly used for documentation to improve accuracy and accessibility.
5. Confidentiality must be maintained when documenting patient information to comply with HIPAA regulations.

Review Questions

• Why is accurate documentation critical in pharmacology for nurses?
• What are the potential consequences of incomplete or incorrect documentation?
• How do Electronic Health Records (EHR) improve the process of documentation?

Related terms

Informed Consent:

A process by which a patient voluntarily confirms their willingness to undergo a particular procedure or treatment after being informed of all the risks, benefits, alternatives, and consequences.

HIPAA: The Health Insurance Portability and Accountability Act that sets standards for protecting sensitive patient information.

Medication Reconciliation:

The process of creating the most accurate list possible of all medications a patient is taking to ensure proper drug therapy.