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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 |
Created by:
caronjones
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