# CTE Resource Center - Verso - Practical Nursing I Task 2101595300

CTE Resource Center - Verso

Virginia’s CTE Resource Center

Describe principles of documentation.

Definition

Description should include use of
  • ethical and legal considerations
  • medical terminology
  • SOAP (Subjective-Objective-Assessment-Plan) charting, SBAR (Situation-Background-Action-Recommendation) communications, narrative charting, checklists, charting by exception
  • confidentiality
  • electronic health records.

Process/Skill Questions

  • What are the ethical and legal issues related to documentation?
  • What criteria are considered universal for all client documentation?
  • How would you write documentation, using accurate, standard medical terminology and abbreviations?
  • What are the basic guidelines and mechanisms of various charting formats?
  • What is considered confidential regarding a nurse's knowledge of the client?
  • What is a nurse's role in informed consent and in advanced directives?
  • What are the ethical and legal issues related to the use of computers in health care?

Related Standards of Learning

English

11.5

The student will read, interpret, analyze, and evaluate a variety of nonfiction texts including employment documents and technical writing.
  1. Apply information from texts to clarify understanding of concepts.
  2. Read and correctly interpret an application for employment, workplace documents, or an application for college admission.
  3. Analyze technical writing for clarity.
  4. Paraphrase and synthesize ideas within and between texts.
  5. Draw conclusions and make inferences on explicit and implied information using textual support.
  6. Analyze multiple texts addressing the same topic to determine how authors reach similar or different conclusions.
  7. Analyze false premises, claims, counterclaims, and other evidence in persuasive writing.
  8. Recognize and analyze use of ambiguity, contradiction, paradox, irony, sarcasm, overstatement, and understatement in text.
  9. Generate and respond logically to literal, inferential, evaluative, synthesizing, and critical thinking questions about the text(s).

12.5

The student will read, interpret, analyze, and evaluate a variety of nonfiction texts.
  1. Use critical thinking to generate and respond logically to literal, inferential, and evaluative questions about the text(s).
  2. Identify and synthesize resources to make decisions, complete tasks, and solve specific problems.
  3. Analyze multiple texts addressing the same topic to determine how authors reach similar or different conclusions.
  4. Recognize and analyze use of ambiguity, contradiction, paradox, irony, overstatement, and understatement in text.
  5. Analyze false premises claims, counterclaims, and other evidence in persuasive writing.

History and Social Science

GOVT.15

The student will apply social science skills to understand the role of government in the Virginia and United States economies by

  1. describing the provision of government goods and services that are not readily produced by the market;
  2. describing government’s establishment and maintenance of the rules and institutions in which markets operate, including the establishment and enforcement of property rights, contracts, consumer rights, labor-management relations, environmental protection, and competition in the marketplace;
  3. investigating and describing the types and purposes of taxation that are used by local, state, and federal governments to pay for services provided by the government;
  4. analyzing how Congress can use fiscal policy to stabilize the economy;
  5. describing the effects of the Federal Reserve’s monetary policy on price stability, employment, and the economy; and
  6. evaluating the trade-offs in government decisions.

GOVT.16

The student will apply social science skills to understand that in a democratic republic, thoughtful and effective participation in civic life is characterized by

  1. exercising personal character traits such as trustworthiness, responsibility, and honesty;
  2. obeying the law and paying taxes;
  3. serving as a juror;
  4. participating in the political process and voting in local, state, and national elections;
  5. performing public service;
  6. keeping informed about current issues;
  7. respecting differing opinions and the rights of others;
  8. practicing personal and fiscal responsibility;
  9. demonstrating the knowledge, skills, and attitudes that foster the responsible and respectful use of digital media; and
  10. practicing patriotism.

Other Related Standards

HOSA Competitive Events

Health Science Events

 

Medical Spelling

 

Medical Terminology

 

Knowledge Test: Medical Law and Ethics

 

Health Professions Events

 

Clinical Nursing

 

Teamwork Events

 

HOSA Bowl