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Transcript of Nursing Documentation
Documentation is any written or electronically generated information about a client that describes the care or service provided to that client.
All entries must be legible.
To facilitate COMMUNICATION
is a method of organizing health information in the patient's record.
Effective documentation reflects the quality of care and provides evidence of each health care team member's accountability in giving care.
To meet PROFESSIONAL & LEGAL STANDARDS
To promote QUALITY NURSING CARE
current individual concern or behavior,
acute change in patient's condition,
a significant event in patient's care,
a key word/phrase indicating compliance with a standard of care or hospital policy,
a NURSING DIAGNOSTIC CATEGORY
It encourages the use of assessment data to evaluate patient concerns.
It is a systematic approach to documenting nursing care organized into patient-centered topics or foci.
Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention.
Completed or planned nursing interventions based on the nurse’s assessment of the client’s status.
Description of the impact of the interventions on client outcomes.
Ineffective airway clearance r/t inability to expectorate secretions
- clear frothy secretions noted; O2Sat 98%; RR=20bpm; crackles still noted on lung auscultation.
-suctioned secretions at 0800H and every 2hours thereafter, -seen by Dr. Mohd at 1000H, no new orders made.
-client semicomatose; excessive oral secretions noted; RR=22bpm; crackles heard over both lung fields
Don't leave blank spaces.
In making corrections, don't use eraser, correction fluid, or blotting out. Draw a line through it and write MISTAKEN ENTRY, with your name.
Each recording must be signed by the nurse making it.
Use only acceptable abbreviations.
All entries on the patient's record must be in permanent ink.
CHERRY KRIS SUAREZ
For EDUCATION & RESEARCH