Nursing 1080A/B Lecture Notes - Lecture 4: Perspiration, Vital Signs, Family Medicine
9 Dec 2016
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Consider spirirtual and cultuaral norms, how we engage with patient, age and stage. Scenario: completed interview with client regarding relation of determinants of health to personal well being. Complete, accurate & reflective of clients journey. Reflective of the work not recorded, not done. Legal record how to manage errors or late entries. Emergency the nurse is accountable for what she does, not what others do. Comprehensive what you do when you see someone annually/for the first time (ie. family doctor). Legality, maintain care, communication, evidence that you know what youre doing, shows what you claim to have done/what you wanted to do, patient-centered care. How documentation is used/how to document: charting by exception. Must be legible, clear, concise, factual, and comprehensive. Use words that have meaning ie. avoid generalizations (seems, appears) professional practice? (does a chart audit) to improve practice. Documentation is used to determine the kind of care the client receives. Using reflection skills when reviewing a patients chart.
