NURS 1014 Lecture Notes - Lecture 3: Blind Signature, Videotelephony, Telehealth
10 Feb 2017
School
Department
Course
Professor
Document Summary
Documentation- written or electronically generated client information obtained through the nursing process. Through documentation rns communicate observations, decisions, actions and outcomes. Standards- identify the level of performance expected of rns in their practice against which actual performance can be measured. Standard 2: knowledge- based practice- 2. 8 maintains timely and accurate documentation. First hand knowledge (you did it or saw it) Co-signing- confirming signature on a witnessed event or activity. Countersigning- a blind signature that is not witness i. e. transcribing mars. Clear, concise, unbiased and accurate (avoid generalizations, avoid bias, identify subjective comments) Admission (baseline information), transfer, transport, and discharge information. Client care provided through electronic means (telehealth, video conferencing, telephone call, faxes, emails) Client education (description of material utilized, materials used for teaching, involvement of family, outstanding issues) Others- e. g. occurrence reports, professional practice forms, public health required reposting. Focus charting- intended to make the client and client concerns and strengths the focus of care.
