NURSE-3101 Lecture Notes - Lecture 9: Trailing Zero, Medical Record, Pain Scale
Document Summary
Written or electronic legal record of all pertinent interactions with the patient. Aim: complete, accurate, concise, factual, organized, timely. Content: record objective data and observations of behavior (not interpretations), don"t generalize. Seems comfortable. (use a pain scale instead): note problems as they occur, in an orderly, sequential manner. Record your nursing intervention and the patient"s response: document in a legally prudent manner, document date/time doctor notified. Document doctor"s name and what you told them. Document the response ( orders received or no orders received ). Timing: document in a timely manner. Follow agency policy regarding frequency of documentation. Modify this if changes in patient"s status warrant more frequent documentation: indicate date and time entry was written. Indicate time of observations and interventions if these are different from time entry is written: document nursing interventions as closely as possible to the time they are performed. The more seriously ill the patient, the greater the need to keep documentation current.
