NSE 13A/B Study Guide - Final Guide: Personal Information Protection And Electronic Documents Act, Nursing Process
1 Sep 2018
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Document Summary
Documentation: anything written or electronically generated that describe status of patient or care or service given to patient. Effective documentation allows communication that can positively affect health outcomes for patients and minimize the risk of errors. Purposes: communication and care planning, legal documentation, research, education, funding and resource management and auditing-monitoring. Nursing documentation: record of nursing process (assessment, diagnoses, outcome identification, planning, implementation, evaluation) Must be accurate, comprehensive, and flexible enough for members of the health care team to retrieve critical data maintain continuity of care, and track patient outcomes, and it must reflect current standards of nursing practice. Nurses are legally and ethically obligated to keep information about patients confidential. Patient information may only be discussed with patient and staff who are directly involved. Personal information protection and electronic documents act (pipeda): act that protects personal information.
