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What is Documentation?
- Is used to monitor a clients progress
- Communicate with other care providers
- Relects the nursing care & accountability
Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes.
ensuring that documentation is a complete recordof nursing care provided and reflects all aspectsof the nursing process, including assessment,planning, intervention
- documenting both objective and subjective data.
- ensuring that the plan of care is clear, current,relevant and individualized to meet the client’s needs and wishes
Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete
- * documenting the date and time that care was provided and when it was recorded
- * documenting in chronological order
- * indicating when an entry is late as defined by organizational policies;
Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures.
- understanding and adhering to policies, standards and legislation related to confidentiality.
- accessing only information for which the nurse has a professional need to provide care.
- maintaining the confidentiality of other clients by using initials or codes when referring to another client in a client’s health record
What are the 3 standard statements of documentation according to CNO?
What are thedifferent types of doumentation?
- Charting by Exception
- Flow Sheets
What is Narrative charting?
- consists of written notes that include routine care.
- this type of charting has no right or wrong order.
- This type of charting is used for emergency only. as it is being replaced by exception and focus charting
Charting by Exception:
is a documentation system which only significant findings are recorded using flow sheets.
- there are 3 key components:
- clinical observation, nursing intervention, & client response to care
- is having computer terminal at clients bedside
- or nurses carry a small hand held terminal or personal digital assistant, allowing the nurse to document immediately after care is given
- is intended to make the clients concerns and strengths the focus of care.
- 3 columns for documentation are used: date and time, focus, and progress notes
- Documentation is
- – Accurate
- – Relevant
- – Timely
- - comprehensiv
COMMUNICATION STANDARD STATEMENT:
Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes
What does PHIPA stand for?
Personal Health Information Protection
(this act outlines the legal collection, use and disclosure of personal health information.)
A primary piece of legislation that impacts security and documentation.
What is a Kardex?
This is used as a quick access to current data about clients
Principles on documentation for Long term care:
are the same for short term care how ever long term care focuses more on daily function preventative measures and restrative care
What 2 things are considered HAND OFF communications?
- 1. A change of shift
- 2. telephone report
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