Perioperative documentation, the recording of a patient's condition, treatment and response to treatment, is one of the most basic nursing skills. But its importance to both the patient and the nurse providing care cannot be overstated. This is because charting fulfills three important functions: first, it provides information about the patient\'s current condition, treatment response, and progress, and communicates this to other healthcare providers. Second, it serves as a legal record of the care provided. Third, it provides information used for reimbursement by third party payers. This course is designed to provide nurses and other health care providers with a basic understanding of the importance of accurate, timely and thorough perioperative documentation. |