Principles of Recording in Nursing

with they increased on the epicenter from BSN.

To be at this point,

I will discuss module for a topic to principles of record in nursing.

Why did I choose this topic? I chose this topic because it is important for us.

Student needs to know how to record a bit of a patient how important this

is and for us not to make any mistake when it comes to recording.

So at the end of this presentation the student will

be able to discuss the importance of proper recording and

documentation in the nursing profession and also with certain understanding

of its significance for effective and efficient patient care.

So far the overview,

proper record keeping is an important aspect of a patient care.

A patient record is a permanent document that chronicles a patient care history.

So let's learn by recordkeeping is important in the

principle of record keeping in the nursing profession.

So let's say you love to cook.

One day you come up with a great new way to make you spaghetti sauce.

You add all the right spices and all the right amount and the result is delicious.

But let's say you forgot to write down the recipe

without a record of how you make your fabulous sauce.

You'll never be able to make it again.

Just like a cook needs to keep detailed records about intelligence and

just like a nurse needs to keep detailed records of a patient.

So in this lesson you will learn why proper recordkeeping is

important and the principle that must be followed to ensure proper record

keeping.

Yeah.

So what is

record keeping.

So record keeping is the act of organizing

and documenting information relevant to inpatient treatment.

A record keeping is the act of tracking it person

history.

Hey,

nexus, what is a patient record?

Patient record is the repository of information about a single patient.

This information is generated by health care professionals as a direct result

of interaction with a patient or individuals who have personal knowledge about

this patient.

So next is

the purpose of this record keeping.

A basic purpose of the nursing documentation is the creation

of database in which the patient files are include.

The patient files is kept for many reasons from which the most important ones are.

So the importance of a of a patient

record is a permanent documentation and if we should

care by health care

provider.

Thanks.

While it might feel as if the nurses interpreting

treatment to write down notes.

Patient records are vitality important to the continuing care of

eight

Pay shed. For example, you as a nurse

encountered 20 different patients in one day or in a day

and it's impossible to remember details about each patient you encounter.

So nurse must learn the principle of good record keeping

because this record serve as a history of a client.

Several reveal patterns. Easy

patient progress

guide future care decision

support, financial building

and may even be used as evidence. It's legal issues.

All right.

So next

the principles of record keeping

records should be written as soon as possible after

impatient

encounter. So

we remember when we talk about the importance of

writing down the recipe of your delicious spaghetti.

Sos

let well

let's say you did remember to write down the ingredients.

However the next time you pull out the recipe it was so full of areas or marks,

confusing abbreviations, shot and illegible writing that you couldn't follow it

like a recipe a patient record must be complete

and written carefully to be

useful. So there are jobs either generally generally principles

rather that nurses must follow to ensure the records do there

chop just like what I said that the curd should be written as soon as possible after

a patient encounter because this quick actually make

it more likely that important details aren't forgotten.

Of course picking notes asap doesn't mean they should be rushed.

Take enough time to ensure that all notes are record neatly.

Patient records must be clear in Vorarlberg.

Next.

Mhm.

If you're not happy with the clarity of the note unique,

remember that record should never be altered or destroyed without

proper

authority. So if you do if you did something wrong, do not erase some states. Instead

draw a line to the mistake and then sign and date the

correct shot.

Mhm.

Yeah.

Next is the principle of record writing sooner.

Should develop their own method of expression and forming record writing.

So all nurses have their own kind of methods on how they will still unable to be

um able to be able to memorize the patient recorders remember the patient details.

So records should be written clearly and appropriately.

Yes but like I said earlier it should be neat and clean

for you to understand and for the position or the doctor understand.

The nexus record should compete facts based on observation,

conversation and action.

Um If you are going to interview your patient or

you're going to ask about details about your patient,

what your patients said to you, it should be created in your

record

in your record about the patient. So next like relevant facts and

the recording should be neat, complete and

uniform

saying what I said earlier. It should be neat and clean but it should be

take a take time

and make sure that

it is clear for you to understand and for the doctor to understand.

So record should be written immediately after an interview. This is

true because you might forgot it unless you have this kind of photographic memory.

But

based on my research it was not yet proven

that people us has this kind of photographic memory.

So records are confidential of humans.

It should be

cap and

doctors I knew as a nurse only know the details about the

patient.

So next is

there's just responsibility for record keeping and reporting.

Keep under safe custody of

nurses.

Next no individual ship should be separated.

It should be organized and next not accessible to patients and visitors.

It couldn't be a lab. It's not allowed for any kind of

strangers. Just like you're strangers are not permitted to read

records of your patient unless

the patient asked for the family asked you about it.

Next records are not handed over

to the legal advisory without treatment permission

of the administration without the signature from the doctor or your position.

And then handed carefully.

Do not destroy and then identify with by elite of the patient things. Age admission

number, diagnosis chatterers or legal

issues and never sent outside the

hospital without written administrative permissions.

Okay.

Mhm.

And keep in mind that patient records are confidential.

Therefore,

nurses must maintain the records as

confidential to protect the patient privacy and

rights never leave patients records where they may give you an authorized person.

So summary record keeping is the act of organizing

and document thing information relevant to a patient care.

A patient record is a permanent documentation of a patient care by health care

provider.

This record serve as a history of a client care revealed patterns,

Very patient progress guide future care decision support,

financial building and they might be used as evidence of illegal

issues arise and principles of record include the following records.

The record should be written as soon as possible after a patient encounter.

It must be clear and legible and should

never be altered or destroyed without proper authority.

If you do something wrong. Do not curious mistakes.

Instead draw a line through the mistake and then sign and the correction.

The records needs to include notes on care that was given

any problem that arose and action taken to deal with the

problems document Every patient refused treatment includes the date time,

any signature,

use standard terminology and abbreviations and avoid

vlog statement that are open to interpretation.

So nurses must maintain the records as confidentiality and that's all.

Thank you.

Principles of Recording in Nursing

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