Credit Hours: 5

Documenting all patient care related activities is an important communication tool for exchange of information between nurses and other caregivers. Effective documentation is a reflection of nursing assessments, changes in clinical state, care provided and critical patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. The quality and coordination of care depends on the communication and exchange of information between different caregivers about their patients. Quality nursing documentation promotes and facilitates continuity and individuality of care and safety of patients and helps avoid errors. Documentation can be done electronically or it can be handwritten. Either ways nurses are expected to follow certain guidelines for effective documentation.

Objectives:

At the end of the course the learner will be able to 

• Appreciate the importance of documentation in nursing practice
• Practice correct documentation using the guidelines for documentation
• Describe the different types of records &reports
• Explain reporting in the hospital setting

Instructor: Ms. Manisha, Nurse Educator, Bodhi Health Education.

Facility: Maharishi Markandeshwar Deemed to be University (MMU), Mullana, Ambala.