NURS194 Chapter Notes -Medical Record, Correction Fluid, Personal Information Protection And Electronic Documents Act
Document Summary
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: communication and care planning: adpie (outlines plan of care), health care team members communicate client"s needs and progress, discharge planning, legal documentation: record care given and response to limit nursing liability.
