HNN120 Lecture Notes - Lecture 5: Professional Responsibility
HNN120
CLINICAL DECISION MAKING
1
DOCUMENTATION
Professional documentation of a patient’s status is both a legal and professional responsibility. It ensures
continuity and timeliness of safe care by providing a mode of communication that is permanent.
- Narrative documentation: recording what is happening as it happens, with the observations,
iteretios ad the patiets respose to iteries oted. This teds to e repetitious.
- Problem-focused documentation: addresses the proles idetified durig the patiets stay i a
chroologial order. A list of the patiets proles i geerated ad uered. Plas are
established to deal with all the problems and as they are resolved they are highlighted as
completed.
- Documentation by exception: this mode of documentation focuses on exceptions to the normal or
deviations from the usual standards. This reduces the amount of time spent documenting.
When to document:
- Upon admission/baseline notation of assessment
- Ineffective treatment/effective treatment
- Any changes (positive or egatie) i the patiets oditio.
Legal requirements:
- Legible and correct spelling/grammar
- Blue/black ink
- Dated using dd/mm/yy system and times using 24 hour clock
- Error free or errors acknowledged using a single line through the error and initials written above
ith error
- Free of blank areas (draw a line through sections not needed)
- Signed and named
- Do not interpret
ROLE OF THE NURSE IN DECISION MAKING
We gather all data, and we classify that clinical information by bringing it together and coming up with an
opinion about it. A diagnosis, decision about what treatments to give, wound to dress etc.
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Document Summary
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