NSG 2113 Study Guide - Final Guide: Learning Disability, Nursing Shortage, Infection
6 Dec 2016
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Must be accurate, comprehensive, flexible, reflective of nursing standards. Documentation and reporting practices differ among institutions and jurisdictions. Ethical, legal, medical, and agency guidelines influence documentation. Tick sheets are really bad for documenting because people are either busy or lazy and don"t ensure that what they"re ticking is actually happening. Ex: nurse ticks that there are bowel movements, when the patient has been constipated for 10 days. Nurses are legally and ethically obligates to keep patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. Patient"s family doctor is not part of the circle of care when the patient is in the hospital. Ex: if the family doctor asks for blood work that was taken, you must say no, but once the patient is discharged they can give their blood work to their doctor. Multidisciplinary communication within the health care team. A professional caregiver providing formal advice to another caregiver. Arrangement fro services by another care provider.
