MEDRADSC 2U03 Lecture Notes - Lecture 5: Process Flow Diagram, Flowchart, Ion
28 Jun 2016
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Document Summary
Permanent documentation in the patient"s chart should be. Progress note should be written in clear, concise language, and should include: An objective description is the result of direct observation and measurement. Include descriptive, objective information about what the therapist sees, hears, feels and smells and any information related to client care but do not record opinions or assumptions. If something is not documented, it could be challenged or assumed that it was not done. For example, if a patient was suctioned, the documentation would include why the client needed suctioning, what the outcome was, and the patient"s response to suctioning. Correct spelling and accurate information demonstrates a level of competency and attention to detail on the part of the therapist. Complete documentation as close to the time of care as possible. This enhances the credibility and accuracy of health-care records. Documentation of an intervention should never be completed before it takes place.
