Recording - Ncm 100
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Transcript of Recording - Ncm 100
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RECORDING /REPORTING
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Recording Records are written accounts of patients observation and
therapy. are written, formal, legal documentation of the
clients progress.
Patients Record/chart/hospital chart- Is a legal document which provides evidence of
the care given to a patient in a particular agency.- Is a communication linkage or system by
which members of the health team exchange
views and information about the patient and histherapy.
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Purposes of Client
Record Planning clientcare
Communication Legal
documentation
Research
Education
Nursing audit
Statistics Accrediting and
licensing
Reimbursement
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Contents of the Patients
Chart1. Face sheet2. Admission Form
3. Medical History
4. Nursing History
5. Graphic Sheet
6. Activity Flow Chart
7. Medication Sheet /Record
8. Doctors order sheet
9. Nurses notes
10. Progress notes
11. Laboratory sheet
12. Problem list
13. Health team notes
14. Discharge plan
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Nurses Notes / charting
is the method used to document, using thenursing process, which includes theobservations that the nurse made about
the patients condition, the statement ofthe problem, the care, and the treatmentthat was delivered and the patientsresponse.
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Guidelines for determining
when charting is required:1. Chart anytime the patients condition warrants
it.
2. Admission date must be recorded as soon aspossible after the patient is admitted.3. Record medication administration as soon as
possible.4. If the patient leaves the nursing unit, make a
notation in the chart before the patient leavesand upon the patients return.5. Chart relevant observation
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6. Record any unusual or untoward incident, thetime, the result of nursing actions and the
patients response promptly and completely.7. Document anytime when the nurse gives care,
treatments, or makes an assessment of thepatient.
8. Visits by members of the health team.
9. The therapeutic measures ordered by thephysician.
10. Specific measures the physician carries out onher own.
11. Evaluation of the effectiveness of nursinginterventions measures both dependent andindependent.
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Guidelines for Recording Writing must be legible On every notation, document the date and time
of the recording and of the assessment orintervention. No recording should be donebefore providing nursing care.
Clients record is restricted to members of thehealth team included on the care of the patient.
All entries on the clients record are made indark colored ink.
Sign each recording and include first and lastname and the title of the person making thenotation.
Accurate notations consist of facts or exactobservations rather than opinions orinterpretations of an observation.
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When describing something, nurses shouldavoid general words such as large, good andnormal.
Correct spelling is essential for accuracy inrecording Errors should not be erased or blotted out. Document events chronologically, what
happens first, next and last.
Only information that pertains to the clientshealth problems and care is recorded. Use only commonly accepted abbreviations,
symbols, and terms that are specified by theagency.
Recordings need to be brief as well ascomplete. Do not leave space between entry. Legal awareness
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Two General Forms of
Records1. Source Oriented / Traditional
Record.2. Problem Oriented / Medical
Record
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1. Source Oriented
Record- Is the information about thepatients care that is narrative form
and is usually charted in chronologicalorder regardless of the topic underconsideration.
- Information is organized accordingto the source of that information.
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2. Problem Oriented
Record (POR)- Is organized according to the
identified problem of the patient.
- All members of the health care teamwrite proper notes about the sameproblem on the same problem on thesame form in the chart.
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Components of POR
1. Baseline Data consist of all the informationabout a patient obtained during admission.
2. Problem List is a series in chronological orderof identified patient problem or diagnosis
- result of manipulation andinterpretation of new information collected inthe database.
3. Initial plan of Care completed as soon aspossible after admission and is the beginning
looking plan of the team.4. Progress notes
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Kinds of Progress Notes
1. Narrative Charting records patient progress ina day to day basis.2. SOAP / SOAPIER format3. PIE charting4. Flow Sheets is designed to facilitate the
recording of recurring treatment or observationin a graphic form.5. Discharge Notes a description of problem
identified, and the degree to which eachproblem has been resolved, accomplished during
the patients discharge6. Discharging a client Against Medical Authority
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Other Written Documentation
Kardex it is a summary of thepatients problem and therapy and is
readily accessible to all members ofhealth team as well as being usedduring changes of shift.