NURS 3120 Lecture Notes - Lecture 3: Vital Signs, Respiratory Rate, Urethra
Document Summary
Why is it important to document? (cid:862)if it is (cid:374)ot do(cid:272)u(cid:373)e(cid:374)ted , it is (cid:374)ot do(cid:374)e(cid:863: we document in the health record so that care is comprehensive across the health care visits. Legal record of our interaction with our patient/client: remember to always do(cid:272)u(cid:373)e(cid:374)t . Accurately, legibly - reflecting analysis & clinical reasoning. Documentation may be electronic or paper depending on the facility. May sometimes also have insurance info on it. Present health status: chronic illnesses, medications. Result in birth, infertility, spontaneous abortion: p: how many delivered (can be 1) Family history: stroke, diabetes, diseases, disorders. Personal status: how do you feel about/view yourself, cultural affiliation, education, job (enjoy, how long at present job, hobbies. Family and social relationships: living status (home and family, children, grandchildren, description of family (closeness, family duties (caring for relatives) Caregiver (stress of mother/father living in home) Diet/nutrition: appetite, changes in weight, balanced food intake, 24-hour recall. Mental health: frustration, despair, support systems.
