Documentation Assignment
Instruction:
Clinical documentation is an important component within the practice of healthcare providers. Healthcare providers are required to make and keep records of their practice. They are accountable for ensuring that their documentation is accurate and meets the practice standards (CNO, 2008). “Documentation presents an accurate, clear and comprehensive picture of the client’s needs, the interventions and the client’s outcomes” (CNO, 2008, p. 6).
In this assignment, use DAR format to make a clinical progress note on an observation/assessment that you made on a client’s condition/behaviour (does not have to be a real-life observation, however information has to make sense medically).
Assessment data, planning/actions and evaluation should be comprehensive and clear providing adequate information about client’s needs, appropriate interventions and client’s outcomes.
Refer to documentation assignment rubric for specific evaluative criteria.
