Worksheet

Overview

Estimated time to complete: 1 hour or less

Target group(s): Nurses and nursing students

Brief summary of assignment:

This activity is related to documentation location and standardized electronic terminology, and requires locating previous documentation of patient data. Appropriate actions you complete include finding patient data in the electronic medical record, identifying the location, noting if the location is appropriate, and, if not, identifying the appropriate location and why.

Learning Objectives

At the end of this activity the learner will be able to:

· Explain the relationship between documentation location and efficient access to patient data and information

· Describe the difference between documenting in standardized query/response lists and documenting a free text comment within electronic assessments

Assignment

1. Log into thePoint and DocuCare, following all instructions given to you earlier.

2. Enter the Documentation Hunt Case.

3. Patient Name / Date of birth: ____________________________________

4. You are coming on to night shift and the day nurse is busy with another patient. While you wait for the report, you review the chart. Complete the following:

5. Submit for review per module instructions.