DeLaune & Ladner (2011) identified a nursing checklist that can be used to assist nurses with understanding what is expected from documentation and what reviewers are looking for when they review a chart

Question

Which of the following is not correct regarding reviewing a chart for effectively documented information? a. Can the assessment data that triggered the nursing diagnosis be identified?
b. When the defining characteristics of a specific nursing diagnosis are compared to the patient's presenting signs and symptoms, is there supporting evidence?
c. Are all the charges documented and reasonable, and is there anything that seems out of line?
d. Were critical questions asked during the patient interview?

Answer 1

C
Documentation provides a legal record of patient care to protect the patient, organization, and nurs-ing/medical practitioners. DeLaune & Ladner's (2011) nursing checklist for documentation provides a good foundation to assist nurses in understanding what reviewers are looking for when they review a chart for specific nursing-related information. Some of the items on this checklist include: 1) can the assessment data that triggered the nursing diagnosis be identified?; 2) when the defining characteristics of a specific nursing diagnosis are compared to the patient's presenting signs and symptoms, is there supporting evidence?; 3) were critical questions asked during the patient interview?; and 4) did the nurse use the data obtained from both the interview and physical assessment in establishing the diagnosis? While ensuring that all charges documented are reasonable, and that nothing seems out of line are both important tasks, these actions are related more to fiscal concerns and are not listed in DeLaune & Ladner's checklist.