3. Learning objectives
Upon successful completion of this lecture, the
student will be able to:
Understand scope of PCT
Recognize scope of documentation
Definition of documentation
List importance of documentation.
Disusse characteristics of documentation
4. Scope of PCT
Patient care technicians help patients by
cleaning the rooms, supporting them with
medicines and basic daily requirements.
Also, they are responsible for assessing
patients’ health and doing basic nursing
operations.
5. Scope of PCT
The Patient Care Technician accurately
records the data gathered per the total count
of patients and registers them in the medical
records.
Also, they notify a Registered Nurse or
Physician of any changes in a patient’s
condition.
6. Scope of PCT
Monitoring the health of patients and
checking vital signs is also the duty of a
Patient Care Technician.
They also ensure that patient records get
appropriately monitored.
7. Scope of documentation of PCT
Accurately documents vital signs, weights,
I&O, restraints, specimen collection, and all
other treatments.
Report changes in patient's physical, mental
and emotional conditions, as well as any
issues or concerns identified to nursing staff.
8. Documentation
It is a written evidence of the interactions
between/among health professionals,
patients, their families and health care of
organization.
9. Documentation
The written, legal record of all patient
interventions with the client assessing,
diagnosis, planning, implementation and
evaluation.
10. Documentation
The written, legal record of all patient
interventions with the client assessing,
diagnosis, planning, implementation and
evaluation.
11. Importance of documentation
To maintain a continuous record of events
over a period of time.
To identify patient problems, to plan and
evaluate that care.
To follow activities performed to the
patient.
12. Legal significance of the medical record
• The medical record provides legal of the nature
and quality of care the patient received.
• A factual, consistent, timely and complete record
defends the health provider against allegations
of negligence, improper treatment and omissions
in care.
• Failure to document implies failure to provide
care.
13. Characteristics of the medical record
• Accurate
• Complete
• Timely
• Contents
• Chronology
• Continuity
