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Reflect
• If I was an agency nurse would I know
what care to provide to a resident from
your care plans?
Evaluating
The health care professional and
resident measure how well the resident
has achieved the planned goals. It is
decided to either terminate the plan,
modify the plan or continue the plan.
Identify factors which have contributed
to the success or failure.
When does a record become a legal
document?
Whenever a document is relevant to an issue
arising in court then it can be lawfully required
to be produced in evidence.
The court can subpoena the disclosure of
Kardex or the nursing-process documents.
Nurses are increasingly liable for improper
documentation of client care because the law
presumes that if the work was not
documented, it was not done.
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Appendices
Re-checking and Evaluating
Re-checking relates to the process of
gathering information after carryng out a
nursing intervention.
It is specific and targeted and linked to a
specific problem or goal.
Think Point
Think about some of your residents: list
five activities that you carried out that
could be considered to be re-checking?
Give an example of evaluation.
Documenting
This documentation is a legal document
and provides a record of the care given
to the resident.
Care not documented is care not given.
Documentation
The clients chart is a permanent legal
record that can powerfully defend or easily
discredit the nurse when questions arise.
Documenting medical records is often
done hurriedly leading to documentation
which is barely legible, unbelievably
incomplete and perhaps legally
indefensible.
(Allen, 1994)