Documenting Expressions

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Documentation in health care is an important communication tool for the health care team as they care for residents/patients. It is important to have medical documentation of individuals’ expressions/ behaviors and the events that precipitated the expressions/behaviors. Without documentation, there is no evidence of what occurred or how to mitigate expressions/behaviors in the future. Included is Tips for Use to help your team get the most out of the “Documentation of Expressions (Behaviors)” resource, which provides examples of both best practices and poor practices for documentation of expressions. The one-page “Documentation of Expressions” resource paired with pre- and post-tests will provide nurses with a solid foundation for clearly communicating what occurred and the steps that were taken by staff to de-escalate the expression or behavior.

Documentation of Expressions: Tips for Use

Documentation of Expressions

Education for Documentation: Pre and Post Learning Assessment

Answer Key: Pre & Post Assessment

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Focus Area(s): Adverse drug event resources, Antipsychotic resources, Behavioral health resource, Care coordination, Nursing Home Quality, Psychotropic Resources, Quality Improvement Resources, Readmissions, Workforce engagement