NSG 2113 Lecture Notes - Lecture 5: Nursing Care Plan, Personal Information Protection And Electronic Documents Act, Flowchart
7 Nov 2016
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Document Summary
Documentation: anything written or electronically generated that describes the status of a patient or the care or service given to that patient. More than 35% of nursing practice time is concerned with documentation. Documentation ensures continuity and quality of care, furnishes legal evidence of care, provides evidence for quality assurance purposes, and constitutes a database for planning future health care. You may not discuss a patient"s examination, observation, conversation, or treatment with other patients or with staff who are not involved with the patients care. Many patients request copies of their health care records and have the right to read their records. Each institution has policies for controlling the manner in which records are shared. As a nurse, we are responsible for protecting records from all unauthorized persons. Nursing students and faculty may be required to present identification indicating that they are authorized to access records. Health care agency stores records after the treatment ends.
