文档介绍：Chapter 16 Nursing Documentation
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medical and nursing documents
client's record
A client's medical record
Temperature sheet
Physician’s order sheet
special nursing record chart , etc.
Change-of-shift report (病室交班报告)
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Section 1 Record and Administration of medical and Nursing Documents
Purpose of Records
Principle of Records
Administration of Medical and Nursing Documents
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Purpose of Records
Providing Information
Providing Basis for Quality Review
Providing Basis for Legal Purpose
Providing Data for Education and Research
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Principles of Records
Timely
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Objective and Accurate
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Complete
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Concise
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Legible
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follow the hospital’s requirement to make documentation at regular intervals.
No recording should be done before providing nursing cares, and delaying or omitting the recording is not acceptable either.
Timely
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Objective and Accurate
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Recording must be accurate and correct.
Accurate recordings consist of facts or observations rather than opinions or interpretation.
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The client's name, age, and bed number, should be written on each page of the record.
Complete
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Leaving no blank lines on the client's chart.
the caregiver must sign his or her full name after recording.
a client's condition is critical.
a client insists on refusing a treatment or leaving the hospital against medical advice.
a client has inclination of committing suicide.
these situations must be filled in the client's chart.
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Concise
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Documentation must be concise, in a logical order, and lay stress on key points.
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All entries must be legible and easy to read.
When a recording error is made, draw a line through it and write the corrector's name above it.
Do not erase, blot out, or use correction fluid.
Legible
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