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NURS194 (1)
Lecture 1

NURS 194 LAB REVIEWER.docx
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Department
Nursing
Course
NURS194
Professor
Jo- Anne Henson
Semester
Fall

Description
4TimelyDOCUMENTATIONANDNursesmustenterdataintotherecordinatimelymannerREPORTING5ConciseFlorenceNightingaleBenarrativeandconcisestraighttothepointFounderofnursingdocumentationRecordpatientinformationinaclearconciseandBatchChartingorganizedmannerWaitingtiltheendoftheshifttodocumentorallFailuresincommunicationpatientsareassessedcontributestopotentialerrorsCommonlytherootcauseoferrorsinhealthcarebecauseanursemayforgetthepreviousassessmentDocumentationClinicalPathwayInvolvesenteringpatientinformationintothewrittenAmultidisciplinarytoolthatidentifiesastandardorcomputerizedpatienthealthrecordplanoraspecificpopulationPatienthealthrecordProgressnoteContainsrecordedinformationintothewrittenorPatientsprogresstowardsrecoverycomputerizedpatienthealthrecordNarrativenotesNursesrecordinanunstructuredparagraphtherelevantassessmentsandnursingactivitiesduringashiftPURPOSESOFPATIENTorvisitHEALTHRECORDSOAPnotes1LegalDocumentFocusesonasingleconditionLegaldocumentofthepatientshealthcarestatusPIEnotesProblemInterventionEvaluation2CommunicationandcareplanningGoalistoincorporatePlanofCarePOCintheAllmembersofthehealthcareteamaccesstheprogressnoteassessmentdatadocumentedtoprovidethebasisfortheplanFocusNoteDARDataActionResponseofcareDAR3QualityAssuranceAnAuditinspectionoccurswhenanagencyreviewsHEADANDNECKtherecordsofahealthcarefacilitytodeterminewhetherthatfacilityisprovidinganddocumentingcertainLYMPHATICASSESSMENTstandardsofcareHead4EducationIncludescraniumandfacialskeletonUsesthistoenhanceclinicallearningandtoNeckunderstandcomplexclinicalsituationSupportedbythecervicalvertebraeC1C75ResearchVertebralprominenceThesedataareusedformedicalresearchUsefulnecklandmarkeasilypalpableLongestvertebraewhichisthespinousprocessofC7ComputerizedProviderOrderEntryCPOETracheatoenterordersdirectlyintothecomputertoAllowsImportantforrespiratorysystemthelabpharmacyandnursingpersonnelThyroidShouldbesymmetricalwithoutdiscretemassesPRINCIPLESOFnodularityortendernessProduceshormonesthatregulatesmetabolicratesDOCUMENTATIONParathyroid1ConfidentialSecretescalcitoninwhichhelpsinbreakingdownofrequiredlegallyandethicallytokeepallNursesarebonestocreatecalciumforthebodyinformationinthepatienthealthrecordconfidentialCanonlybediscussedwithhealthcareprofessionalsthatareinvolvedinthepatientscareLYMPHATICS2Accurateandcomplete1PreauricularNursesmustaccuratelyrecordandreflectonwhat2Posteriorauriculartheyobservedheardauscultatedpalpatedpercussedor3Occipitalsmelled4SuperficialcervicalMUSTBEPRECISEASPOSSIBLEexinsteadof5Deepcervicalsayingheartbeatisgoodandnormalsayheartrateand6PosteriorcervicalrhythmisregularlungsoundsCLEARinsteadoflung7Submentalsoundsaregood8Tonsillar3OrganizedDemonstratesalogicalandsystematicprogressof9Submandibularinformation
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