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Charting and Monitor

understand the importance of documentation

QuestionAnswer
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
Created by: caronjones