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ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings.
General principles for documentation. General considerations for documenting include: Documentation should detail information such as assessment findings, risks related to care, the plan of care for the person, modifications to the care plan, interventions performed, and an evaluation of care provided.
nursing documentation that is used throughout an organization. ANA’s Principles for Nursing Documentation identifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings."
Nursing documentation is essential for clinical communication. Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care.
Six Principles of Nursing Documentation. The American Nurses Association (ANA) has identified six principles of nursing documentation to provide guidance for producing high quality documentation (ANA, 2015). 1. Documentation Characteristics. Accessible. Accurate and relevant. Auditable.
Six Principles of Nursing Documentation. The American Nurses Association (ANA) has identified six principles of nursing documentation to provide guidance for producing high quality documentation (ANA, 2015). . Documentation Characteristics. Accessible. Accurate and relevant. Auditable. Clear, concise, comprehensive, and thoughtful.
The RN and the APRN are responsible and accountable for the nursing documentation that is used throughout an organization. This publication identifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings.
Documenting information accurately and comprehensively ensures continuity of care, supports clinical decision-making, manages risk, and aids in evaluating the effectiveness of interventions. The ANA has articulated six principles for high-quality documentation by nurses (Table 14.7) (ANA, 2010).
ANA’s Principles for Nursing Documentation identifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings. American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492. 1-800-274-4ANA.
Principles of Documentation. As a nurse, you are legally obligated to complete documentation. You should refer to the legislative and regulatory requirements for documentation in the province or territory that you work.