Defensible Documentation Using the Endoscopy Pathway
- 1 March 1999
- journal article
- research article
- Published by Wolters Kluwer Health in Gastroenterology Nursing
- Vol. 22 (2) , 38-46
- https://doi.org/10.1097/00001610-199903000-00002
Abstract
Complete, defensive documentation in a busy endoscopy unit can be elusive. Quick runaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.Keywords
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