Learning Plan on Hospital Documentation

Nurses General Nursing


Hello Everyone!

I am trying to complete a learning plan on documentation. My goal is to become familiar with documenting at the hospital for clinical. I am stuck on success indicators. This is what I have so far:

Goal: To become more familiar with documentation at the hospital.

Success Indicators: I will be able to document at the hospital following all required guidelines with no supervision.

Now, the indicators just doesn't sound right to me! Can anyone give me some ideas on how to word this? Any input on both of my sentences? I could really use the help!

I appreciate it in advance,

Amy :)

Specializes in Critical Care, Education.

You need to create measurable indicators & goals. Otherwise, how will anyone know that you have met your goal? How can you quantify "familiar"? I think you actually want to be able to meet or exceed the facility's documentation requirements, right?

Think about the process of measuring & evaluating your documentation. What sort of things would you look at? Whenever you are trying to evaluate anything having to do with 'quality', always think of three different areas for indicators: Structure, Process & Outcome.


Structure: legiblility, use of proper forms, Pt ID on all forms

Process:completed on time, no block charting, etc.

Outcome:(documentation meets pre-determined criteria for)

* Efficacy of PRN pain meds noted

* Patient teaching recorded

* Physical assessment findings - or you could focus on a single area

* Rhythm strip interpretation as per policy

* Communication with physician


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