The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation? (Select all that apply.)

Question

a. Helps provide continuity of care
b. Standardizes patient care parameters
c. Assists in maintaining confidentiality
d. Reduces the number of medication errors
e. Provides the foundation for staffing levels
f. Allows for quality evaluations among units

Answer 1

A, B, E, F
An institution uses the same nursing documentation record because it helps provide continuity of care across various settings by providing organized, pertinent, and thorough health care data on a specific individual. Other units in the hospital and other health care settings have an easier time locating relevant data. Specific health care data are found in one location on a standardized nursing documentation record throughout an institution and provide the basis for standardized patient evaluation across settings. Standardized documents help describe patient acuity levels and thus provide a justification for staffing. Because the same parameters are, or should be, recorded across all units, the standardized documentation record allows for hospital-wide quality evaluations. Nurses must restrict access to a standardized documentation record or any other type of patient record such as laboratory reports, narrative or progress notes, and other documents. A standardized nursing documentation record can reduce a specific type of documentation error but is unlikely to affect the rate of medication errors.