NSG 2113 Study Guide - Final Guide: Electronic Health Record, Personal Information Protection And Electronic Documents Act, Organism

• School: University of Ottawa
• Department: Nursing
• Course: NSG 2113
• Professor: Stephanie Janveux

Document Summary

Lecture 8 documenting & reporting: multidisciplinary team every health care provider in the patient"s circle of care , documentation. Anything written or electronically generated that describes the status of a patient or the care or service given to that patient compilation of patient info = patient record or chart. Cno professional practice standards: documentation, con dentiality and privacy-personal health information, ethics, professional standards. #1: any identifying verbal, written or electronic info about a client. Tuesday, january 2, 2018 ie) physical or mental health, family health history, care received, payments or eligibility for health care, donation of parts, tests, health. Purpose of documentation: communication, care planning and continuity of care, meet legal requirements, demonstrate accountability, education, data source, quality improvement initiatives (auditing, research, organizational and government planning. Tuesday, january 2, 2018: nursing flowsheet (medications given, vital signs, weight), graphic record, Intake/output: medication administration record (mar), diabetic record. Factual: accurate, complete, current, organized and timely, compliant with standards.