NURSING 2L03 Chapter Notes - Chapter 3: Antibiotics, Concussion, Hypotension
24 Oct 2016
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Group learning activities: how information is documented. Ensure that high standards for documentation and management of health care records are maintained consistent with common law, legislative, ethical and current best practice requirements. Allows access to patient information upon request from those involved in patients care and patient. Not all documentation is legal documentation- written notes are just for nurses purpose. Documentation develops an organized comprehensive care plan amongst all health care team. Challenges with documentation: abbreviations, unclear of what person was trying to say, difficult to maintain-updated, lack of key info (missing or forgotten, time consuming, unstructured. Must include: patients name, age, physician, medical diagnosis, summary of progress, current health status, allergies, emergency code status, family supports, care plan, any critical assessments or interventions to be completed shortly after transfer, need for special equipment. Event that is not consistent with the routine operation of heath care unit or patient care. Falls, sick visitors, med error, injury or risk of injury.
