NSE 13A/B Lecture Notes - Lecture 3: Electronic Health Record, Abdominal Pain, Advance Healthcare Directive
5 Oct 2016
School
Department
Course
Professor
Document Summary
Nursing documentation focuses on your assessment of the client, what you have done as the nurse and your. September 20, 2016 plan of care for them. Kardex; thick piece of paper done in pencil (only exception), allergies written in red pen, includes med, activities, all key info of the day etc. Other forms: informed consent, advance directives, diagnostic studies and discharge reports. Legal expectation (if its not written down, it didn"t happen) Correction of errors 9 but a single line through the error so that it can still be read and doesn"t look like you are trying to hide something) Reflective of subjective and objective data (avoid unfounded conclusions and value judgements) Document why you think so; they are sweating, have an increased heart rate etc. : patient does not seem to have pain . If you suspect that the client is in pain, ask them.
