NSE 13A/B Lecture Notes - Lecture 3: Nursing Process
18 Jun 2017
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Nse13 week 3 objectives: define documentation and describe the legal guidelines for reporting and recording, and how these relate to the health history. Documentation is the recording of the nursing process. Reflective of subjective and objective data: practice documentation using a variety of methods such as narrative, soap(ie), and. Identify the elements of, and practice, verbal report using sbar tool. N/a: verbally report and record health history data, including subjective and objective data, using narrative, flow sheets, and medical terminology. N/a: critique documentation findings that record subjective and objective data obtained using sample documentation notes provided. N/a: discuss common medical terminology as well as abbreviations and acronyms and potential risks of using them.
