It is comprehensive but flexible enough to change with changing organizational and policy needs It reflects the quality of care and holds providers accountable for the care they provide. They enable providers to track care and the patients response to interventions. They provide an opportunity for consistency, reflect standards and how they are being met.
Factual: objective information from the sensesNo: appears, seems or apparently. Use the client’s words
Nursing history: includes relevant bio, hx, current problem, dx. Serves as the baseline for care. Graphic or flow sheet: for routine repetitive care for ease of following normal course. Serves as jumping off point for focused charting. Ht, wt, VS, fluids I&O, ETC Mar: MEDICATIONS TIME, ROUTEDOCUMENTATION PRINCIPLES Comprehensive and flexible Quality and continuity Track patient outcomes Reflect current standards
Source records each discipline has its own section for charting. The information about any one problem i.e. tb may be through out the chard unlike a PMOR.
Mr. X. received from Night shift. Oriented to time, place & person. Breathing spontaneously on room air, RR=20/m. B.P 110/ 70mmgh, pulse=80/m. chest tube in placed with bubbling & column movement present. catheter in placed urine output 30ml/hr, stool passed normally. IV fluids 100ml / hr continue for 24 hrs.________ A.Razzak.