NURS 3400 Chapter Notes - Chapter 18: Prescription Drug, Blood Transfusion, Electronic Health Record
Document Summary
Documentation: the act of recording patient status and care in written or electronic form or in combination of the 2 forms. Care: in chronological order, provided by all health care providers. Important facts about a client"s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. Includes: admission data, advance directive, history and physical, Provider"s orders, progress notes, diagnostic studies, laboratory notes, nurses" notes, graphic data, rehabilitation and therapy notes, and discharge planning. A system of charting in which only significant findings or exceptions to standards and norms of care are charted. Chart signs and symptoms that may indicate actual or potential client problems. After analyzing , document your clinical nursing judgment about the client"s response to actual or potential health conditions or needs. Document a measurable and achievable short-term and long-term plan of care with goals directed at preventing minimizing, or resolving identified client problems or issues.
