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nur documentation

nursing documentation

8 reasons for documentation communication, education, assessments & planning, research, auditing, legal documentation, agency accreditation, reimbursement
flow sheets repetitive documentation, quick reference, faster documentation, MAR, nursing care for 24 hours, VS
narrative charting summary of routine care, normal findings, patient problems. chronological order.
charting sequence describe the assessment of patient, nursing interventions, evaluation
charting concise, accurate, factual, written documentation and communication of occurrences and situations pertaining to a patient
federal statutes medicare, medicaid
state statutes nurse practice act, department of health
JCAHO joint commission on accreditation of healthcare organizations
problem oriented medical record data is arranged according to the problem the patient rather than the source of the information
charting by exception documentation system in which only abnormal or significant findings or exceptions to norms are recorded
computerized charting use computers to store patients database, add new data, create and revise care plans and document patients progress
the following information should be charted doctor visit, calls to MD, stat meds, prn meds, treatments, refusal of meds or treatments
charting and the nursing process nursing process provides the framework for decision making throughout all phases of nursing care. relate the nursing process and charting in the patient record
standard of care detailed guidelines that represent the predicted care indicated in a situation, define professional practice and nursing care, care/critical pathways
source orientated medical records each person or department makes notation in a separate section of patient chart, information about a problem is distributed throughout the record
nursing kardex medical diagnosis, info needed for daily care, accessible, written plan of care, diet, activity, orders, saftey precautions, scheduled tests and procedures
Created by: kamia2010