2
AssignmentMultiple Select

Observation and Reporting Skills

Question 2 • Introduction to Health Science - EL3601 B

Denise, a nursing student, has been trying to improve her documenting skills. Which skills should she focus on in her training? Select all that apply.

Answer
A
writing factual, clear, and accurate information legibly
B
writing the documentation as close to the time of care as possible
C
dating additional information
D
writing all information in emphatic order or order of importance
E
using approved abbreviations and symbols
F
using notebook paper to record information

Explanation

Good documentation is factual, clear, accurate, and legible, and it should be recorded as soon as possible after care. Any additional or late information should be dated (and identified according to facility policy). Nurses should use only approved abbreviations and symbols. Information should generally be documented in chronological order, not emphatic order, and notebook paper is not an appropriate substitute for the approved health record.

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