NSE 13A/B Lecture Notes - Lecture 3: Ibm Db2, Nursing Process
Document Summary
Used to organize assessment data for verbal communication. Tate you(cid:396) (cid:374)a(cid:373)e, u(cid:374)it, patie(cid:374)t"s (cid:374)a(cid:373)e, (cid:396)oo(cid:373) (cid:374)u(cid:373)(cid:271)e(cid:396) a(cid:374)d patie(cid:374)t"s p(cid:396)o(cid:271)le(cid:373) B (cid:271)a(cid:272)kg(cid:396)ou(cid:374)d: state data pe(cid:396)ti(cid:374)e(cid:374)t to this (cid:373)o(cid:373)e(cid:374)t"s p(cid:396)o(cid:271)le(cid:373); ad(cid:373)itti(cid:374)g diag(cid:374)osis, ti(cid:373)e of admission. A assessment: what do you think is happening in regard to the current problem, state which body system you think is involved. R recommendation: what do you (cid:449)a(cid:374)t the physi(cid:272)ia(cid:374) to do to i(cid:373)p(cid:396)o(cid:448)e the patie(cid:374)t"s situatio(cid:374) Nurses must follow certain principles to maintain confidentiality of information. Legally and ethically obligated to keep information about patients confidential. Only staff directly involved have legitimate access to the records. Whe(cid:374) the (cid:862)(cid:272)ase(cid:863) is do(cid:374)e, the (cid:374)u(cid:396)se should dispose the i(cid:374)fo(cid:396)(cid:373)atio(cid:374) (cid:272)o(cid:396)(cid:396)e(cid:272)tly i(cid:374) a se(cid:272)u(cid:396)e (cid:271)i(cid:374) for shredding. Record: (cid:272)o(cid:374)fide(cid:374)tial, pe(cid:396)(cid:373)a(cid:374)e(cid:374)t legal do(cid:272)u(cid:373)e(cid:374)t of i(cid:374)fo(cid:396)(cid:373)atio(cid:374) (cid:396)ele(cid:448)a(cid:374)t to a patie(cid:374)t"s health (cid:272)a(cid:396)e. Report: oral, written or audiotaped exchanges of information between caregivers.