NURS194 Chapter Notes -Medical Record, Correction Fluid, Personal Information Protection And Electronic Documents Act

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11 Nov 2011
Documentation and Reporting Principles
- Documentation is anything written or electronically generated that describes the status of a
client or the care or service given to that client. Effective documentation can positively affect
the quality of life and health outcomes for clients and minimize the risk of errors.
- Nurses are legally and ethically obligated to keep information about clients confidential. Most
cases require written permission from client to release their medical information (if they wish to
see it).
- Personal information protection and electronic documents act (PIPEDA) is federal legislation
that protects personal (health) information. This act outlines how private sector organizations
may collect, use, or disclose personal information.
- A client’s record, or chart, is permanent legal documentation of information relevant to a
client’s health care. Purpose of a client’s health record includes:
o Communication and care planning: ADPIE (outlines plan of care), health care team
members communicate client’s needs and progress, discharge planning.
o Legal documentation: record care given and response to limit nursing liability. Charting
should be performed immediately after care is provided.
o Education: include diagnoses, signs and symptoms of disease, successful and
unsuccessful therapies, and client behaviours. Client health record helps teach the
nature of the illness and client’s response to illness. Helps to anticipate the care
required for a client by identifying patterns for various health problems.
o Funding and resource management: shows how health care agencies have used their
financial resources.
o Research: statistical data relating to the frequency of disorders, complications, use of
specific medical and nursing therapies, recovery from illness, and deaths can be
gathered from client records as part of a quality improvement program.
o Auditing-monitoring: helps to evaluate the quality and appropriateness of care.
Documentation Guidelines
- Charting must be accurate, detailed and concise.
- Use only approved abbreviations for your agency and correct spelling.
- Do not erase - apply correction fluid or scratch out errors - cross through the word with a single
line, initial, date, and time and then enter the correct information or provide an explanation.
- Enter only objective descriptions of client's behaviours - - avoid subjective comments.
- Enter client quotes using quotation marks.
- Do not leave blank spaces in nurse's notes. Use a straight line to fill the space.
- Be sure all entries are legible and in black ink.
- Chart only for yourself.
- Avoid vague terms like "good day" use specific descriptions of care.
- Begin each entry with date and time; end with your signature and title.
- Record important changes as they occur. Do not wait until the end of the shift.
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