NURS103 Study Guide - Final Guide: Debt Management Plan, Medical Diagnosis, Nursing Care Plan
25 Aug 2016
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Document Summary
Documentation= anything written or electronically generated that describes the status of a client or the care/service given. Documentation must be: accurate, comprehensive, flexible enough for others to get crucial data, maintain continuity of care, track patient outcomes, and must reflect current standards of nursing practice. Provides detailed account of quality of care delivered to patients. Ensures continuity and quality of care, legal evidence of care, provides evidence for quality assurance purposes, and creates database for planning future health care. Effective documentation-> positively affect quality of life and health outcomes for client and minimize the risk of errors. Data recorded, reported, or communicated to other health care professionals are confidential-> must be protected. Legally and ethically obligated to keep info about client confidential. Can"t discuss anything w/ anyone not involved the patient"s care: only staff directly involved in patients care have legitimate access to the records. Patients have the right to read their records.
