Title: Describe principles of documentation.
Course: Practical Nursing I (14052-I) > Section: Describing Legal, Ethical, and Professional Responsibilities in Clinical Practice

Description should include use of

- ethical and legal considerations
- medical terminology
- subjective-objective-assessment-plan (SOAP) charting, Situation-Background-Action-Recommendation (SBAR) 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 one 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?
- What are steps the nurse can take to safeguard client information during documentation at point of service?