NSG 2113 Lecture Notes - Lecture 6: Medical Record, Nursing Process, Surrogate Decision-Maker
9 Feb 2017
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Nsg2113 lecture 6 notes: documentation and medication administration. Documentation is anything written of electronically generates that describes the status of a patient or the care or service given to that patient. Documentation must be accurate, comprehensive, flexible, reflective of nursing standards. Ethical, legal, medical, and agency guidelines influence documentation. Why we document: reflect the client"s perspective, communicate clien"t health status and responses to care to all health care team, demonstrate safe, ethical care, demonstrate knowledge, skills, judgement, meet professional standards of care. All aspects of the nursing process which. Provide a clear picture of: relate to the clients plan of care: client"s needs and goals, the nurses actions based on the needs assessment, the outcomes and evaluation of those actions. Records of chart: confidential permanent legal document. Reports: oral, writtem audiotaped exchange of information. Consultations: a professional caregiver providing formal advice to another caregiver. Referrals: arrangement for services by another health care provider.
