After completing this chapter the students will be able to:
- Discuss the purposes of documentation.
- Explain how to communicate within the health care team.
- Explain how various forms of clients records are used to document the steps of nursing process.
- List the principles of Reporting.
- Compare & contrast the different documentation methods.
- Identify & discuss the essential guidelines for reporting client data.
- Identify essential guidelines for effective recording that meets legal & ethical standards.
- Identify prohibited abbreviations, acronyms & symbols that cannot be used in any forms of clinical documentation.
