SF Documentation and Recording Q#2

Records are used to serve to document the history of the client, assist in the continuity of care, as evidence to support or to manage or face the legal questions that arise, and to recognize the health needs and can be used as a research and teaching tool.

• For the Individual and Family

• For the Doctor

• For the Nurse

• For Authorities

Serves as guide for diagnosis, treatment, follow up and evaluation of services, indicate progress and continuity of care, help self evaluation of medical practice, protects them in case of legal issues, and may be used for teaching and research.

• For the Individual and Family

• For the Doctor

• For the Nurse

• For Authorities

Provide with documentation of services rendered, i.e. shows health condition of the client, provide data essential for planning and evaluation of services for further improvement, and serve as a guide for professional growth.

• For the Individual and Family

• For the Doctor

• For the Nurse

• For Authorities

Provide the management with statistical information necessary for decision in regard to utilization of resources, planning for administrative control and future references, help the supervisor evaluate the services rendered, teaching done and a person’s action and reactions.

• For the Individual and Family

• For the Doctor

• For the Nurse

• For Authorities

No individual sheet is separated from the complete record unless, as with the doctor’s order sheet, it is kept in a special place where its safety is guarded.

• Protection from loss

• Safeguarding its content

• Completeness

• Responsibility for nurses’ notes

The hospital administration usually has a procedure with which the head nurse should be familiar for handling legal matter of this kind. Patient has the right to insist that his record be confidential.

• Protection from loss

• Safeguarding its content

• Completeness

• Responsibility for nurses’ notes

The two parts of the record for which the nursing service is universally wholly responsible are the vital sign, graphic sheet and nurses’ observation or nurses’ notes.

• Protection from loss

• Safeguarding its content

• Completeness

• Responsibility for nurses’ notes

Follow the SMART model or similar when planning care. SMART means? Select/tick all that apply.

• Specific

• Measurable

• Artistic

• Realistic

• Time-based

Describe objective measurements or observations about clients’ condition and response to health problems. Stress recent change, but do not use critical comment about clients’ behavior.

• Change- of- shift reports or 24 hours report

• Transfer reports

• Incident reports

• Census report

These reports involve communication of information about clients from the nurse on sending unit to the nurse on the receiving unit.

• Change- of- shift reports or 24 hours report

• Transfer reports

• Incident reports

• Census report