NUR 1021C Chapter Notes - Chapter 1: Fluid Balance, Financial Compensation
8 Jun 2020
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Document Summary
Information charted can be too vague: ehr ensures that time and date is captured, however, a note may be required to specify exactly. Lack of detail when charting nutritional intake can lead to ineffective clinical decision making. what the client ate. Writing sloppy or illegibly: some facilities still use hand-written charts, nurses handwriting is sometimes illegible, the use of abbreviations may be confusing to other healthcare professionals. If information is not conveyed correctly, patient care is delayed. Real-time charting: chart things as they happen, charting activities at the end of your shift may lead to loss of important information. Inaccurate i/o"s can lead to a late diagnosis. Lack of information can lead to fluid imbalance. It is common for new nurses to take a couple of months to become proficient at charting. Consequences: death/harm to patient, stress to the nurse, financial compensation, reputational damage. Solutions: ehr, training, education, standardized documentation, good work practices.
