The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
The document discusses the importance and purposes of documentation in nursing. Effective documentation allows nurses to communicate about patient care, promotes good nursing practices, and supports meeting legal and professional standards. It should provide an accurate account of assessments, interventions, and patient outcomes. The SOAP format is commonly used to document patient encounters and ensure comprehensive yet concise notes.
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
This document discusses different methods of nursing documentation. It describes narrative documentation, problem-oriented medical records (POMR), SOAP/IER notes, PIE notes, and focus charting. It also defines different types of nursing diagnoses like actual, risk, and potential complications. Nursing documentation is an important part of ensuring high-quality patient care. Proper documentation includes recording assessments, care provided, and evaluation of outcomes.
The document discusses various patterns of nursing care delivery systems used in India. It defines nursing care delivery as combining nursing services to meet patient needs across care settings. The key elements include clinical decision making, work allocation, communication, and management. Traditional methods like case method, functional method, and team method are explained along with their advantages and disadvantages. Advanced methods like case management, critical pathways, and primary nursing are also summarized. Factors influencing nursing care delivery systems are organizational policies, staffing, education, budgets, and patient needs.
This document discusses ambulatory care nursing. It defines ambulatory care nursing as nursing care for patients who receive treatment on an outpatient basis and do not require overnight hospital admission. The setting can include clinics, patient homes, and other outpatient facilities. Ambulatory care nurses focus on pain management, health education, medical screenings, triage, and case management to help patients live independently. Conceptual models for ambulatory care nursing practice include the clinical model, levels of prevention model, and primary health care/managed care models. The roles of nurses in ambulatory settings include enhancing safety, coordination of care, leadership, and providing services through telehealth, physicians' offices, urgent care centers, and other settings. Trends in
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
The document discusses the importance and purposes of documentation in nursing. Effective documentation allows nurses to communicate about patient care, promotes good nursing practices, and supports meeting legal and professional standards. It should provide an accurate account of assessments, interventions, and patient outcomes. The SOAP format is commonly used to document patient encounters and ensure comprehensive yet concise notes.
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
This document discusses different methods of nursing documentation. It describes narrative documentation, problem-oriented medical records (POMR), SOAP/IER notes, PIE notes, and focus charting. It also defines different types of nursing diagnoses like actual, risk, and potential complications. Nursing documentation is an important part of ensuring high-quality patient care. Proper documentation includes recording assessments, care provided, and evaluation of outcomes.
The document discusses various patterns of nursing care delivery systems used in India. It defines nursing care delivery as combining nursing services to meet patient needs across care settings. The key elements include clinical decision making, work allocation, communication, and management. Traditional methods like case method, functional method, and team method are explained along with their advantages and disadvantages. Advanced methods like case management, critical pathways, and primary nursing are also summarized. Factors influencing nursing care delivery systems are organizational policies, staffing, education, budgets, and patient needs.
This document discusses ambulatory care nursing. It defines ambulatory care nursing as nursing care for patients who receive treatment on an outpatient basis and do not require overnight hospital admission. The setting can include clinics, patient homes, and other outpatient facilities. Ambulatory care nurses focus on pain management, health education, medical screenings, triage, and case management to help patients live independently. Conceptual models for ambulatory care nursing practice include the clinical model, levels of prevention model, and primary health care/managed care models. The roles of nurses in ambulatory settings include enhancing safety, coordination of care, leadership, and providing services through telehealth, physicians' offices, urgent care centers, and other settings. Trends in
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
Nursing documentation is an integral part of nursing practice that promotes high quality patient care, continuity of care, and communication between healthcare providers. It provides an accurate account of a patient's treatment, care plans, and the care delivered. Nursing records are read by nurses, patients, relatives, doctors, and other healthcare team members. Registered nurses are professionally accountable for ensuring complete, factual, consistent, and clear documentation that demonstrates their assessment, care planning, actions taken, and arrangements made for patients. Nursing documentation can be used in legal matters and audits help assess record standards and identify areas for improvement.
This document outlines 4 goals to improve patient safety at a healthcare facility. Goal 1 is to correctly identify patients to ensure safety during diagnosis, treatment and administrative processes. Goal 2 aims to improve communication effectiveness among caregivers to reduce errors. Goal 3 focuses on improving safety of high alert medications by establishing specific handling and administration procedures. Goal 4 seeks to ensure correct site, procedure and patient for surgeries. The goals provide policies and procedures and designate staff responsibilities to address issues and enhance patient safety.
nursing process is the base or heart of complete nursing and nursing process gives the framework for the nurses in giving care to the patient the knowledge of nursing process is must to become a licensed nurse or to practice nursing this ppt give nurses a brief idea what all thing are including in nursing process and to determine efficiency, knowledge, skills and attitude of personnel and can make best use of their skills into clinical practice.
The document discusses the nursing process, which is a framework that guides nursing practice through a systematic problem-solving method. It involves 5 steps - assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through interviews, exams, and tests. Nursing diagnosis identifies the client's response to problems. Planning develops goals and interventions. Implementation carries out the interventions. Evaluation determines the effectiveness of the nursing care plan. The nursing process provides individualized, goal-oriented care and promotes critical thinking in nursing.
\nNurses play an important role in quality improvement by monitoring for adverse events and complications, and providing timely care to patients experiencing issues. Quality improvement in nursing involves reviewing data to identify areas for improvement, formulating goals, and evaluating nursing performance to improve patient care and work environment. Nurses can collect quality improvement data through various tools like patient safety surveys, error reporting, and record reviews. Common nursing quality indicators include falls, pressure ulcers, pain assessment, and staffing levels.
Documentation in nursing serves several key purposes: to communicate information about patient care, support legal requirements, and enable quality assurance. There are various types of documentation including recording and charting. Common documentation systems are problem-oriented medical records, problem-intervention-evaluation, and computerized documentation. Nurses must follow best practices for documentation like using objective language and maintaining patient privacy, while correcting errors and documenting all teaching.
The document outlines principles for proper documentation, including:
1) Documentation must be consistent, complete, accurate, concise, factual, organized and timely.
2) Entries should include date, time, legible writing, correct spelling, permanent ink, accepted terminology, factual and objective information, accuracy, and completeness.
3) Documentation should be in sequence, appropriate, current, concise, organized, signed, and keep all information confidential.
This document discusses the planning phase of the nursing process. Planning involves setting priorities, establishing goals, and selecting interventions. It describes initial planning, ongoing planning, and discharge planning. Guidelines are provided for developing different types of nursing care plans such as informal, formal, standardized, and individualized plans. The planning process involves setting priorities, establishing goals and desired outcomes, selecting nursing interventions, and writing nursing orders.
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
Documentation and reporting in healthcare involves recording information in patient records and communicating information to other healthcare providers. Patient records contain key identifying and clinical information to provide an accurate record of a patient's care over time. Records are used for communication between providers, planning care, quality assurance, research, education, reimbursement, and legal documentation. Effective documentation and reporting requires following guidelines such as recording factual, dated, legible, permanent, unambiguous information in the proper sequence and manner according to healthcare organization policies.
This document discusses nursing documentation policies and procedures. It covers the purposes of documentation which are to serve as communication between healthcare members, provide a permanent legal record, and ensure continuity of care. It also discusses different types of documentation like the problem-oriented charting format and flowsheets. The document provides guidance on documenting verbal/telephone orders, panic lab results, and handovers. It emphasizes adhering to hospital policies and procedures to maintain patient and staff safety.
MICRO TEACHING ON DOCUMENTATION OF NURSING PROCESS
Nursing documentation clearly describes: • An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; • Information reported to a physician or other health care provider. INTRODUCTION
3. DEFINITION Nursing Documentation: Any written or electronically generated information about a client that describes the care or service provided to that client. “Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise.
4. • To facilitate communication • To promote good nursing care • To meet professional and legal standards PURPOSE FOR DOCUMENTATION
5. Benefits of the Nursing Notes Nursing documentation provides: • An account of judgment • Critical thinking used in the nursing process.
6. Cont… Accurate, timely documentation reflects care provided: • Professional, legislative, & agency standards • Enhance nursing care • Facilitate communication b/w nurses & other health care providers.
7. DOCUMENTATION PRINCIPLES • Comprehensive and flexible • Quality and continuity • Track patient outcomes • Reflect current standards • Patient identification on every page of the record • Date, time and name/initials.
8. GUIDELINES FOR DOCUMENTATION • Factual • Accurate • Complete • Current • Organized
9. CONSEQUENCES OF INADEQUATE DOCUMENTATION • Fragmented care • Repetition of tasks • Delayed therapy • Omitted therapy • Delayed recovery
10. Refrences •DUGas, B., Esson, L. & Ronaldson, S.(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480
A 1991 study identified several major problems facing nursing in 119 countries including India. These included a lack of nurses prepared for administrative roles, acute staffing shortages, and poor relationships between nursing education and services. Additional issues included a lack of nursing authority, weak teamwork and collaboration, insufficient resources, and unsupportive administrative structures. The document further discusses various employment, ethical, legal, and practice issues impacting the nursing profession.
The document discusses the planning phase of the nursing process. It defines planning as the systematic phase where goals and expected outcomes are established and nursing interventions are selected based on evidence. There are three types of planning: initial planning done on admission, ongoing planning done by nurses on each shift, and discharge planning which starts on admission to anticipate post-discharge needs. The planning process involves prioritizing issues, establishing goals and interventions, and developing a formal written nursing care plan.
Acute and critical care, IN NURSING, MANAGEMENT OF CLIENT IN ICU.dharmendra raval
This document provides an overview of acute and critical care nursing. It discusses how hospitals have changed and now care for sicker patients as outpatient care has increased. Acute care hospitals are defined as having average patient stays of less than 30 days. Critical care units care for the sickest patients in the hospital, using advanced technology and monitoring. The future of acute care nursing will involve caring for an aging population and greater emphasis on cost containment and multicultural care.
INTEGRATION OF NURSING EDUCATION INTO NURSING SERVICES.pptxrangappa
The nursing profession is faced with increasingly complex health care issues driven by technological & medical advancements, an ageing population, increased numbers of people living with chronic disease and increased costs of health care services.
Collaboration is a substantive idea repeatedly discussed in health care circles.
Though the benefits are well validated, collaboration is seldom practiced.
This document discusses effective communication skills in nursing practices. It begins by defining communication and its importance in nursing. The document then outlines the communication process, including the sender, message, channels of communication, receiver, and feedback. It also discusses types of communication including verbal, nonverbal, and written. Barriers to communication and skills to improve communication are presented, such as listening skills, managing stress, and assertiveness. The document concludes by examining the effect of communication skills at different levels including nurse to nurse, nurse to superiors, nurse to subordinates, and nurse to clients.
Standards and audit for quality assurancerohini154
Standards and nursing audit are important tools for quality management in nursing. Standards provide agreed upon levels of excellence and measurable performance. Nursing audit involves systematically evaluating nursing care against standards by analyzing nursing records. This helps identify strengths and weaknesses to improve care quality. Standards and audits satisfy the public trust that nursing continuously seeks better health outcomes. Audits are done retrospectively by reviewing records or concurrently by observing care. They require criteria, data collection, analysis, and using results to modify care and education as needed. Standards and audits thus help ensure nursing provides the highest quality care possible.
Nursing documentation is an integral part of nursing practice that promotes high quality patient care, continuity of care, and communication between healthcare providers. It provides an accurate account of a patient's treatment, care plans, and the care delivered. Nursing records are read by nurses, patients, relatives, doctors, and other healthcare team members. Registered nurses are professionally accountable for ensuring complete, factual, consistent, and clear documentation that demonstrates their assessment, care planning, actions taken, and arrangements made for patients. Nursing documentation can be used in legal matters and audits help assess record standards and identify areas for improvement.
This document outlines 4 goals to improve patient safety at a healthcare facility. Goal 1 is to correctly identify patients to ensure safety during diagnosis, treatment and administrative processes. Goal 2 aims to improve communication effectiveness among caregivers to reduce errors. Goal 3 focuses on improving safety of high alert medications by establishing specific handling and administration procedures. Goal 4 seeks to ensure correct site, procedure and patient for surgeries. The goals provide policies and procedures and designate staff responsibilities to address issues and enhance patient safety.
nursing process is the base or heart of complete nursing and nursing process gives the framework for the nurses in giving care to the patient the knowledge of nursing process is must to become a licensed nurse or to practice nursing this ppt give nurses a brief idea what all thing are including in nursing process and to determine efficiency, knowledge, skills and attitude of personnel and can make best use of their skills into clinical practice.
The document discusses the nursing process, which is a framework that guides nursing practice through a systematic problem-solving method. It involves 5 steps - assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through interviews, exams, and tests. Nursing diagnosis identifies the client's response to problems. Planning develops goals and interventions. Implementation carries out the interventions. Evaluation determines the effectiveness of the nursing care plan. The nursing process provides individualized, goal-oriented care and promotes critical thinking in nursing.
\nNurses play an important role in quality improvement by monitoring for adverse events and complications, and providing timely care to patients experiencing issues. Quality improvement in nursing involves reviewing data to identify areas for improvement, formulating goals, and evaluating nursing performance to improve patient care and work environment. Nurses can collect quality improvement data through various tools like patient safety surveys, error reporting, and record reviews. Common nursing quality indicators include falls, pressure ulcers, pain assessment, and staffing levels.
Documentation in nursing serves several key purposes: to communicate information about patient care, support legal requirements, and enable quality assurance. There are various types of documentation including recording and charting. Common documentation systems are problem-oriented medical records, problem-intervention-evaluation, and computerized documentation. Nurses must follow best practices for documentation like using objective language and maintaining patient privacy, while correcting errors and documenting all teaching.
The document outlines principles for proper documentation, including:
1) Documentation must be consistent, complete, accurate, concise, factual, organized and timely.
2) Entries should include date, time, legible writing, correct spelling, permanent ink, accepted terminology, factual and objective information, accuracy, and completeness.
3) Documentation should be in sequence, appropriate, current, concise, organized, signed, and keep all information confidential.
This document discusses the planning phase of the nursing process. Planning involves setting priorities, establishing goals, and selecting interventions. It describes initial planning, ongoing planning, and discharge planning. Guidelines are provided for developing different types of nursing care plans such as informal, formal, standardized, and individualized plans. The planning process involves setting priorities, establishing goals and desired outcomes, selecting nursing interventions, and writing nursing orders.
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
Documentation and reporting in healthcare involves recording information in patient records and communicating information to other healthcare providers. Patient records contain key identifying and clinical information to provide an accurate record of a patient's care over time. Records are used for communication between providers, planning care, quality assurance, research, education, reimbursement, and legal documentation. Effective documentation and reporting requires following guidelines such as recording factual, dated, legible, permanent, unambiguous information in the proper sequence and manner according to healthcare organization policies.
This document discusses nursing documentation policies and procedures. It covers the purposes of documentation which are to serve as communication between healthcare members, provide a permanent legal record, and ensure continuity of care. It also discusses different types of documentation like the problem-oriented charting format and flowsheets. The document provides guidance on documenting verbal/telephone orders, panic lab results, and handovers. It emphasizes adhering to hospital policies and procedures to maintain patient and staff safety.
MICRO TEACHING ON DOCUMENTATION OF NURSING PROCESS
Nursing documentation clearly describes: • An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes; • Information reported to a physician or other health care provider. INTRODUCTION
3. DEFINITION Nursing Documentation: Any written or electronically generated information about a client that describes the care or service provided to that client. “Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise.
4. • To facilitate communication • To promote good nursing care • To meet professional and legal standards PURPOSE FOR DOCUMENTATION
5. Benefits of the Nursing Notes Nursing documentation provides: • An account of judgment • Critical thinking used in the nursing process.
6. Cont… Accurate, timely documentation reflects care provided: • Professional, legislative, & agency standards • Enhance nursing care • Facilitate communication b/w nurses & other health care providers.
7. DOCUMENTATION PRINCIPLES • Comprehensive and flexible • Quality and continuity • Track patient outcomes • Reflect current standards • Patient identification on every page of the record • Date, time and name/initials.
8. GUIDELINES FOR DOCUMENTATION • Factual • Accurate • Complete • Current • Organized
9. CONSEQUENCES OF INADEQUATE DOCUMENTATION • Fragmented care • Repetition of tasks • Delayed therapy • Omitted therapy • Delayed recovery
10. Refrences •DUGas, B., Esson, L. & Ronaldson, S.(1999). Nursing Foundation: A Canadian Perspective. Scarborough: Prentice Hall Canada, P. 480
A 1991 study identified several major problems facing nursing in 119 countries including India. These included a lack of nurses prepared for administrative roles, acute staffing shortages, and poor relationships between nursing education and services. Additional issues included a lack of nursing authority, weak teamwork and collaboration, insufficient resources, and unsupportive administrative structures. The document further discusses various employment, ethical, legal, and practice issues impacting the nursing profession.
The document discusses the planning phase of the nursing process. It defines planning as the systematic phase where goals and expected outcomes are established and nursing interventions are selected based on evidence. There are three types of planning: initial planning done on admission, ongoing planning done by nurses on each shift, and discharge planning which starts on admission to anticipate post-discharge needs. The planning process involves prioritizing issues, establishing goals and interventions, and developing a formal written nursing care plan.
Acute and critical care, IN NURSING, MANAGEMENT OF CLIENT IN ICU.dharmendra raval
This document provides an overview of acute and critical care nursing. It discusses how hospitals have changed and now care for sicker patients as outpatient care has increased. Acute care hospitals are defined as having average patient stays of less than 30 days. Critical care units care for the sickest patients in the hospital, using advanced technology and monitoring. The future of acute care nursing will involve caring for an aging population and greater emphasis on cost containment and multicultural care.
INTEGRATION OF NURSING EDUCATION INTO NURSING SERVICES.pptxrangappa
The nursing profession is faced with increasingly complex health care issues driven by technological & medical advancements, an ageing population, increased numbers of people living with chronic disease and increased costs of health care services.
Collaboration is a substantive idea repeatedly discussed in health care circles.
Though the benefits are well validated, collaboration is seldom practiced.
This document discusses effective communication skills in nursing practices. It begins by defining communication and its importance in nursing. The document then outlines the communication process, including the sender, message, channels of communication, receiver, and feedback. It also discusses types of communication including verbal, nonverbal, and written. Barriers to communication and skills to improve communication are presented, such as listening skills, managing stress, and assertiveness. The document concludes by examining the effect of communication skills at different levels including nurse to nurse, nurse to superiors, nurse to subordinates, and nurse to clients.
Standards and audit for quality assurancerohini154
Standards and nursing audit are important tools for quality management in nursing. Standards provide agreed upon levels of excellence and measurable performance. Nursing audit involves systematically evaluating nursing care against standards by analyzing nursing records. This helps identify strengths and weaknesses to improve care quality. Standards and audits satisfy the public trust that nursing continuously seeks better health outcomes. Audits are done retrospectively by reviewing records or concurrently by observing care. They require criteria, data collection, analysis, and using results to modify care and education as needed. Standards and audits thus help ensure nursing provides the highest quality care possible.
The document discusses various uses and guidelines for medical record documentation. It covers tracking patient progress, sharing information between providers, maintaining patient confidentiality, ensuring quality of care through audits, meeting requirements for insurance reimbursement, using records for research, and providing legal evidence. Key aspects that must be documented include assessments, nursing diagnoses, interventions, patient responses and outcomes. The document also reviews different charting styles like SOAP and problem-oriented documentation.
There are several purposes of nursing documentation including providing a written record of patient care, guiding reimbursement, and serving as legal evidence. Documentation follows the nursing process and is organized by problems, interventions, and evaluations. Common documentation methods include narrative charting, problem-oriented medical records, focus charting, and computer-assisted charting. Accuracy, brevity, legibility, and completeness are important principles of nursing documentation.
Nursing documentation (ND) involves recording a patient's care and is important for communication, facilitating good care, and meeting legal standards. Accurate ND describes assessments, interventions, and outcomes; and information reported to physicians. Benefits include providing a record of critical thinking, reflecting care quality, and demonstrating nursing's unique contributions. Principles include being comprehensive, reflecting standards, and having identifying information. Inaccurate examples lack details, while accurate examples fully describe a patient's condition and care.
What is documentation and its techniquesSohail Sangi
The document discusses the importance of documentation in nursing. It outlines reasons for documentation such as continuity of care, communication between healthcare professionals, and detecting early changes in a patient's condition. It also discusses barriers to documentation and legal requirements regarding patient access to their medical records. Proper documentation is important for protecting patient welfare and for potential use as evidence in legal cases.
In Pharma and Biotech, Weightage of the Documentation is around 70 % because as per FDA "If you do not have Document, You dint have do it."
So Good Documentation Practice is of tremendous importance for the Industry to comply any regulation like FDA, GMP or ISO.
This document provides an overview of the features and functions of Microsoft Word. It explains how to create and save files, edit and format text including fonts, paragraphs, headers and footers, check spelling and grammar, insert special characters, print, add images, set page layouts, and add tables. Key features covered include bolding, italics, underline, font selection, alignment, line spacing, headers and footers, page numbers, symbols, print preview, clipart, borders, searching and replacing text, and inserting tables.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.
The document discusses various aspects of documentation and reporting in healthcare. It defines documentation as written records of interactions between providers and patients, as well as tests, treatments, and patient education. Documentation serves purposes like accountability, communication, education, reimbursement, and legal standards. There are different types of medical and nursing records that contain things like patient data, assessments, diagnoses, treatments, and progress. Effective documentation is factual, accurate, complete, current, and organized. Common documentation methods include narrative, problem-oriented, focus, and computerized charting. Forms for recording data include kardex, flow sheets, progress notes, and discharge summaries. Reporting involves verbal communication of patient status and can occur during shift reports or interdisciplinary rounds
Documentation and reporting are important communication techniques for healthcare providers. Documentation provides a written record of interactions between healthcare professionals and clients, as well as test results, treatments, and client responses. Reporting involves sharing client care information between two or more people. The purposes of client records include communication, legal documentation, research, education, quality assurance, and reimbursement. Effective documentation is accurate, complete, organized, and uses common terminology and abbreviations. Common types of records include nursing assessments, care plans, flow charts, and progress notes.
The document discusses the nursing process and documentation. It describes the 5 steps of the nursing process as assessment, diagnosis, planning, implementation, and evaluation. It then explains each step in detail including types of assessments, sources of data, nursing diagnoses, care planning, interventions, and evaluation. The document also discusses principles of documentation, various documentation systems, and specific documentation tools like progress notes and discharge summaries.
The document discusses patient record systems and nursing documentation. It defines key terms like records, reports and kardex. It describes different types of patient record systems including narrative documentation, problem-oriented medical records, focus charting and source records. It outlines principles of record writing, different documentation methods, advantages of proper record keeping and common record keeping forms used. The document also discusses records management mechanisms, issues related to patient records and role of records in nursing education and public health.
The nursing process is a systematic, cyclical approach to planning and providing patient care. It consists of five core phases - assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting patient data through various methods like interviews, examinations, and record reviews. Diagnosis identifies the patient's actual or potential health problems. Planning develops goals and interventions. Implementation puts the care plan into action. Evaluation assesses the patient's response to interventions and progress toward goals. The nursing process provides structure and organization to nursing care and aims to promote optimal patient outcomes.
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
Introduction to Medical records and Documentation revised 01-13kbpennington
This document provides guidance on navigating a medical record to find pertinent patient information. It outlines the typical sections of a medical record including the initial physician assessment, progress notes, nursing notes, labs, medications, radiology reports, and documentation from other healthcare professionals. It emphasizes the importance of accurate and thorough documentation in medical records for legal and care purposes. Common documentation formats like SOAP, narrative, and problem-oriented records are also overviewed.
The document discusses documentation in healthcare, including its definition, purposes, principles, types of records, and methods of communication and documentation systems. Documentation involves recording all interactions with clients and is used for communication, quality assurance, reimbursement, legal accountability, research, and other purposes. Common types of records include outpatient/inpatient records, nurses' notes, doctors' orders, lab reports, and intake/output charts. Methods of communication include shift reports, telephone reports, and evaluation reports. Documentation systems include source-oriented records, problem-oriented records, and computerized documentation.
The nursing process is a framework for providing patient-centered care that involves 5 steps: assessment, diagnosis, planning, implementation, and evaluation (ADPIE). It is a cyclic and ongoing process used to address any health issues identified for the patient. The steps include comprehensively assessing the patient's health status and needs, diagnosing any issues needing attention, planning care in collaboration with the patient, implementing the planned care, and evaluating outcomes to determine if goals were met or if revisions are needed.
Focus charting describes documenting from the patient's perspective about their current status, progress towards goals, and response to interventions. It uses a focus column that incorporates the patient's concerns, therapies, responses, and functional health. The focus charting includes data about observations, actions describing nursing interventions, and response describing the patient outcome. The purpose is to bring focus back to the patient and their priorities in a holistic way.
nursing process . In nursing management.TulsiDhidhi1
The document discusses the nursing process, which is a problem-solving framework used by nurses to provide patient-centered care. It includes assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient. Nursing diagnosis identifies patient problems/needs. Planning develops goals and interventions. Implementation puts the plan into action. Evaluation assesses progress towards goals and effectiveness of the nursing process. The nursing process provides structure for delivering care and problem-solving to achieve optimal patient outcomes.
documentation and reporting in Nursing and other studentsEsundaraBharathi
This document discusses various aspects of nursing documentation and reporting. It defines documentation and describes its purposes, which include professional responsibility, communication, education, research, and legal standards. It also outlines elements of effective documentation like use of common vocabulary, legibility, accuracy, and confidentiality. Different methods of documentation are presented, including narrative charting, problem-oriented charting, and computerized documentation. Common forms used for recording data like flow sheets and progress notes are also discussed. The document concludes by covering various types of reporting in nursing.
DOCUMENTATION IN NURSING HOSPITAL AL ZAHRA BANGIssuser2a6d06
This document defines nursing documentation and discusses its purposes and types. Documentation has several purposes, including communication, education, and providing a legal record. The main types of documentation are recording and charting. The document also examines common documentation systems, do's and don'ts of documentation, forms used, and a nurse's responsibilities regarding documentation.
The document discusses the nursing process and how it is used to create nursing care plans and concept maps. It outlines the 5 steps of the nursing process - assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting comprehensive patient data. Diagnosis identifies the patient's problems or nursing diagnoses. Planning determines goals and interventions. Implementation puts the plan into action. Evaluation assesses outcomes and the effectiveness of the plan. Concept maps provide an innovative way to organize patient data using diagrams of problems and interventions.
This document discusses the importance and objectives of Drug Utilization Reviews (DUR), Drug Utilization Evaluations (DUE), and Medication Use Evaluations (MUE) led by clinical pharmacists. It outlines the pharmacist's key role in identifying prescribing trends, improving drug therapy, and reducing costs through these programs. The document then details the clinical pharmacist's responsibilities in DUE, including recommending goals, coordinating the process of data collection, analysis, reporting and follow up. It provides guidance on topic selection, developing criteria and standards, collecting data, analyzing results, reporting findings and implementing interventions or corrective actions.
The document discusses measurement theory and practice in health services research. It defines key concepts of measurement including reliability and validity. Reliability ensures consistent measurement and validity ensures the measurement accurately captures the underlying construct. The document describes different levels of measurement from nominal to ratio scales and how they capture variation. It also discusses sources of error in measurement and methods to evaluate reliability and validity, including test-retest reliability and internal consistency.
The document discusses the nursing process and how it is used to create individualized care plans for patients. It outlines the 5 steps of the nursing process - assessment, diagnosis, planning, implementation, and evaluation. For each step, it provides details on how to perform that step, such as collecting comprehensive assessment data, identifying nursing diagnoses, setting goals and interventions, and evaluating outcomes. It also discusses concept maps as an alternative approach to traditional nursing care plans.
The document discusses the nursing process and how it is used to create individualized care plans for patients. It outlines the 5 steps of the nursing process - assessment, diagnosis, planning, implementation, and evaluation. For each step, it provides details on how to perform that step, such as collecting comprehensive assessment data, identifying nursing diagnoses, setting goals and interventions, and evaluating outcomes. It also discusses concept maps as an alternative approach to traditional nursing care plans.
Similar to Different Types of Nursing Documentation Methods (20)
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Different Types of Nursing
Documentation Methods
There are two categories of documentation methods in nursing such as
documentation by inclusion and documentation by exception. In the former, nurse
practitioners make note of all assessment findings, nursing interventions and client
outcomes on an ongoing, regular basis. In the latter, they make note of negative
findings and this documentation is completed when review findings, nursing
interventions or client outcomes show a variation from the established assessment
norms / standards of care prevailing in a particular practice setting. The common
documentation methods in these categories are focus charting, SOAP charting and
narrative charting. Nurse practitioners can select any of these methods, but ensure
that the selected method reflects client care needs and the context of practice.
Focus Charting
This documentation method focuses on particular client concerns/behaviors, a
change in the client’s condition/behavior, or a significant event in the client’s
treatment determined during the assessment. In the documentation, three columns
are utilized for focus charting or F-DAR charting such as:
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Date and Hour – The relevant date and time are added here (for example,
20/10/2014, 7.30pm)
Focus – This represents focus of care, which may be a current concern or
behavior of the client, a change in a client’s condition or behavior or a significant
event in the client’s treatment (for example: pain, hyperthermia)
Progress Notes – These are organized into Data, Action and Response, which is
referred to as DAR format.
Data (D) – This is the assessment phase of the nursing process which
includes subjective and/or objective information that supports the focus
stated on the chart or describes the client status during the time of a
significant event or intervention (for example, if the stated focus is pain, then
the practitioner should note down what type of pain, the location of pain and
how patient feels under Data).
Action (A) – This represents the planning and implementation phase of the
nursing process where completed or planned nursing interventions based on
the assessment of the client’s status is described (for example, medicines,
advices, exercises). Changes to the plan of care are also included in this
section.
Response (R) – This section is the evaluation phase of the nursing process
in which the impact of the interventions on client outcomes is described (for
example, if pain is the focus, then the observation whether pain is relieved or
not is mentioned under Response)
Flow sheets and checklists are often used as an adjunct in order to document
routine and ongoing assessments as well as observations including vital signs,
personal care, etc. It is not required to repeat the information noted down on flow
sheets in the progress notes.
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SOAP Charting
SOAP charting uses a problem-oriented approach to documentation in which nurses
first identify and list out patients’ problems and documentation is done on the basis
of identified problems. This type of documentation is typically organized in the
following manner:
Subjective (S) – Nurses document how the patient actually feels in this
section such as symptoms, patients’ complaints, medication side effects and
so on. The patient’s own words are used as much as possible.
Objective (O) – This section represents objective data including results of
the physical exam, vital signs, lab results and studies.
Assessment (A) – In this section, the patient’s status such as the diagnosis,
prognosis, treatment, and side effects is documented along with the patient
profile (age, sex, occupation, martial status and significant characteristics)
Plan (P) – The medication strategy, planned tests and discharge plans are
documented in this section. The section also discusses whether the plan stays
the same or whether any changes are needed.
Flow sheets and checklists are used frequently as an adjunct along with SOAP
charting.
Narrative Charting
In this method, the patient’s status, nursing interventions and patients’ responses to
those interventions are documented in chronological order covering a specific time
frame. This information is typically included in progress notes and is supplemented
by other tools including flow charts and checklists. It is required to document the
patient assessments whenever the institution demands and more frequently when
the following things are observed.
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Change in the patient's condition
Patient’s response to a particular treatment or medication
No improvement in the patient's condition
Patient’s or family member's response to teaching
It is required to document what you hear, observe, inspect, do or teach along with
specific descriptive information as much as possible. You should also include
notification to the physicians if changes occurred. The physician’s response, new
orders that need to be followed and the patient’s response should be documented as
well. You can use a head-to-toe approach to organize your notes or you can refer to
the care plan and document the patient’ progress with respect to the plan and any
unresolved problems.
Whichever documentation method you select, make sure that it reflects client care
needs and the context of practice. Certain institutions may combine elements of
different documentation methods and formats. There should be a standard
documentation procedure within the healthcare institution and if the institution
changes its method or format, it should be done within the context of appropriate
planning, involvement of nurses and their education. Accurate and standard
documentation improves the communication between physicians and nurses,
promotes good nursing care and helps to meet professional and legal standards.
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