When completing documentation on each client, the nurse recognizes that documentation serves what purposes? (Select all that apply.)
a. It communicates to others whether or not care was received.
b. It conveys pertinent information about the client's condition and response to treatment interventions.
c. It substantiates the quality of care by showing adherence to care standards.
d. It provides evidence for reimbursement.
e. It serves as a source of data that can be compiled or aggregated and then analyzed to establish "best practice" interventions.
f. It is not a source for communicating care to others due to HIPAA rules and regulations.
ANS: A, B, C, D, E
Documentation serves five purposes:
¥ It communicates to others care received or not received.
¥ It conveys pertinent information about the client's condition and response to treatment interventions.
¥ It substantiates the quality of care by showing adherence to care standards.
¥ It provides evidence for reimbursement.
¥ It serves as source of data that can be compiled or aggregated and then analyzed to establish "best practice" interventions. This includes electronic data, which can be aggregated to monitor outcomes of care processes for quality improvement, a QSEN competency.
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