NSG 2113 Lecture 8: Documentation and Reporting Lecture
27 Nov 2017
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Document Summary
Documentation and reporting (p/p ch 8+15 wk 1 back) Anything written that describes the status of the pt or care/service given to pt : uses the nursing process (explicitly like soap or implicit) Pt chart = compilation of all pt information. Protection act: phipa governs health care information privacy in ontario; set a rules managing phi and client rights, allows balance of pt rights and health care needs and access; permits sharing of. Phi among hct; requires info to be kept secure with passwords/firewalls etc. Phi (personal health information: any identifying verbal, written, e-info about client that it highly personal and private (includes physical/mental health, family history, care received, payments, organ donation, health #, anything that could identify a specific patient. Huge impact of not documenting; if no reports are written, then nothing is assumed to be done with the pt. Up to the nurse to prove that a specific standard of care was given.
