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Charting and Monitor
understand the importance of documentation
Question | Answer |
---|---|
Communication needs to be | clear accurate and legible |
Communicate with | health care team,patient |
Why document | provides legal accountability, funding, monitors and evaluates outcomes informs other health care workers |
Legal equirements of documentation re medication | generic name of medication/fluid, strength and dose,route, frequency, times of administration,indication and duration of medication Mo must write and sign their name |
Legal requirements documentation | clear and legible blue or black pen, dated and signed by prescriber, patients name and ID number, allergy status. |
Legal requirements continued | start with date and time and nursing, no vacant lines or spaces, name title and signature of entrant, 2 nurses to sign IV medications |
Where to document | IV medication fluid order chart,FBC, medication chart, progress notes, additive label on IV flask or burette |
What to document, preperation and insertion | observations,avoid generalisations,preperation and insertion, guage of IV device and patency,why ordered, informed consent,date and time of insertion and when to change |
What to document orders and delivery | assessment, vitals, type of IV fluid/ medication, appearance of site, pt response, lab results, order and rationale discontinuation orders |
What not to document | non professional opinions, events that have no bearing on patient care subjective data |
Clinical pathway | identifies expected care for patient |
Nursing progress notes | client condition, plan of care, nursing interventions, evaluation of client response to interventions |
IV charting | order labeled correctly,legal and legible, fluid, route, dose time, date and prescriber |
FBC | 24 hour indication of patients FB |
Sensible loss input | oral NGT intravenous |
Sensible loss output | Urine vomit NGT other |
Reasons to monitor FB | post operative, unstable client, fluid restriction, cardiac history, renal history, neurological disorder |