NSG 2113 Study Guide - Final Guide: Electronic Health Record, History Of Nursing, Biotransformation

• School: University of Ottawa
• Department: Nursing
• Course: NSG 2113
• Professor: Joanne Savory

Document Summary

Form on communication to promote continuity of care to protect ourselves legally. Must be accurate, comprehensive, flexible and reflective of the nursing standards. Ethical, legal, medical and agency guidelines influence documentation. Pt has right to see their (cid:272)hart (cid:894)therefore do(cid:374)"t (cid:271)e judge(cid:373)e(cid:374)tal(cid:895) Only chart things that has to do with pt: x (cid:862)u(cid:374)a(cid:271)le to do this (cid:271)(cid:272) short staffed(cid:863, x (cid:862)pt (cid:272)a(cid:374)"t use (cid:272)rut(cid:272)hes (cid:271)(cid:272) other (cid:374)urses did(cid:374)"t tea(cid:272)h hi(cid:373) properly(cid:863) Legally and ethically obligated to keep pt info confiedential. Nurses responsible for protecting records from all unauthorized readers. Ca(cid:374) o(cid:374)ly share i(cid:374)fo (cid:449)ith other (cid:373)e(cid:373)(cid:271)ers of (cid:862)(cid:272)ir(cid:272)le of (cid:272)are(cid:863: fa(cid:373)ily do(cid:272)tor (cid:272)a(cid:374)"t de(cid:373)a(cid:374)d i(cid:374)fo u(cid:374)til after dis(cid:272)harge, ca(cid:374)"t gi(cid:448)e details o(cid:448)er pho(cid:374)e, make sure to exit and log out of computer. Records or charts: confidential, permanent, legal document. Reports: oral, written, audiotaped, exchange of info. Consultations: professional caregiver providing formal advice to another caregiver. Referrals: arrangement for services by another care provider.