Utilizing critical reasoning and the nursing process, the student is expected to:
1. Discuss the purposes of the patient records
2. Discuss the legal guidelines for electronic and paper documentation
3. Describe how to maintain confidentiality, privacy, and security mechanisms within the medical record
4. Describe the guidelines for effective documentation
5. Discuss the different methods of documentation
6. Identify the different standardized nursing documentation forms
7. Discuss the importance of acuity rating systems
8. Discuss the nurse's role in communicating with other healthcare professionals by reporting and conferring
a. Telephone calls made to a providers and taking telephone and verbal orders
b. Change of shift notes
c. Incident reports
d. SBAR
9. Describe nursing informatics and information management in health care
1. Review module objectives.
2. Learning Resources:
Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A. M., & Ostendorf, W. R. (2025). Fundamentals of nursing (12th ed.). Elsevier.
Chapter 26 Informatics and Documentation pp. 391-408
3. Complete Critical Thinking Exercises:
Documentation Student Learning Guide
4. Supplemental Learning:
See Bb
5. Review module objectives and check for knowledge gaps.
6. Go to the Evolve website and review the module content and practice questions.