The document discusses various aspects of documentation and reporting in healthcare settings. It covers the purposes of documentation including communication, legal documentation, research, statistics, education, audit and quality assurance, and planning client care. It describes different types of client records including source oriented, narrative charting, problem-oriented, and computerized records. It provides guidelines for documentation including confidentiality, accuracy, brevity, appropriateness, completeness, and use of approved terminology and abbreviations. It also discusses different methods of documentation like SOAPIE notes, PIE charting, FOCUS charting, and kardex. Finally, it covers different types of reporting including change of shift reports, telephone reports, and incident reports.
The document provides guidelines for documentation and reporting in healthcare. It discusses the purposes of documentation including communication, planning care, auditing, research, education, reimbursement, legal documentation, and healthcare analysis. It outlines various types of documentation including admission notes, change of shift notes, progress notes, transfer notes, and discharge notes. The document also discusses principles of accurate documentation including being factual, timely, legible, using accepted terminology and signatures. It provides examples of different documentation formats like narrative charting, APIE charting, and SOAP charting.
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.
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 & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
Records and reports documtation 1st bsc ppt.pptxgj17092003
Records and reports are practical aids for healthcare providers to document services and ensure quality care. Nursing records require clear, accurate documentation of a patient's assessment, care plan, treatment, and evaluation. Good record keeping is important for communication among providers, billing, research, and fulfilling legal and ethical obligations. Maintaining organized, confidential records according to standard procedures helps provide comprehensive care and protect all parties.
The document provides guidelines for proper nursing documentation. It discusses principles of documentation including being factual, accurate, complete, concise, and using accepted terminology and spelling. It emphasizes documenting in chronological order, with date, time, and signature. Corrections should have single line drawn through and initialed rather than erased. Documentation must maintain patient confidentiality and nurses are accountable for their own entries.
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.
I. Documentation and reporting are professional responsibilities of healthcare practitioners that provide written records of patient care, assessments, interventions, and responses.
II. Effective documentation requires clear, concise, accurate, and organized recording of all patient information and events in a chronological fashion while maintaining confidentiality.
III. The purposes of documentation include professional accountability, communication, care planning, education, research, and meeting legal standards.
The document provides guidelines for documentation and reporting in healthcare. It discusses the purposes of documentation including communication, planning care, auditing, research, education, reimbursement, legal documentation, and healthcare analysis. It outlines various types of documentation including admission notes, change of shift notes, progress notes, transfer notes, and discharge notes. The document also discusses principles of accurate documentation including being factual, timely, legible, using accepted terminology and signatures. It provides examples of different documentation formats like narrative charting, APIE charting, and SOAP charting.
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.
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 & Reporting In Nursing Practice.pptxDipon11
This document discusses documentation and reporting in nursing practice. It provides guidelines for proper documentation including using dates, times, legible writing, correct spelling, permanence, accuracy, sequence, appropriateness, completeness, conciseness, organization, and signatures. Documentation serves several purposes such as providing a record of care, guiding reimbursement, and serving as potential legal evidence. Different types of reports in nursing are also outlined including change of shift reports, transfer reports, and incident reports.
Records and reports documtation 1st bsc ppt.pptxgj17092003
Records and reports are practical aids for healthcare providers to document services and ensure quality care. Nursing records require clear, accurate documentation of a patient's assessment, care plan, treatment, and evaluation. Good record keeping is important for communication among providers, billing, research, and fulfilling legal and ethical obligations. Maintaining organized, confidential records according to standard procedures helps provide comprehensive care and protect all parties.
The document provides guidelines for proper nursing documentation. It discusses principles of documentation including being factual, accurate, complete, concise, and using accepted terminology and spelling. It emphasizes documenting in chronological order, with date, time, and signature. Corrections should have single line drawn through and initialed rather than erased. Documentation must maintain patient confidentiality and nurses are accountable for their own entries.
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.
I. Documentation and reporting are professional responsibilities of healthcare practitioners that provide written records of patient care, assessments, interventions, and responses.
II. Effective documentation requires clear, concise, accurate, and organized recording of all patient information and events in a chronological fashion while maintaining confidentiality.
III. The purposes of documentation include professional accountability, communication, care planning, education, research, and meeting legal standards.
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.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community settings.
documentation and reporting for nursing students. this session deals with important of proper documentation and its legal implications, thus can reduce errors.
Dear all,
Recording & Reporting are very important in the nursing profession. As a nurse, we have to be very conscious of it to prevent further complications.
1) Nursing documentation is important for communication, accountability, and providing quality patient care. It involves recording all relevant information about a patient's condition, treatment, and the nursing care provided.
2) There are various methods of documentation, including traditional source-oriented records, problem-oriented records, and nursing process frameworks like PIE (Problem, Intervention, Evaluation) charting. Electronic health records are also increasingly common.
3) Proper documentation principles include recording objective factual information, using accepted terminology, keeping accurate and organized records, maintaining client confidentiality, and signing and dating all entries. Thorough documentation is essential for ensuring safe and coordinated care.
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.
The document discusses guidelines for effective nursing documentation. It outlines content, timing, format, accountability, and confidentiality guidelines. It also discusses the purpose of client records for communication, planning care, auditing, research, education, reimbursement, and legal documentation. Finally, it describes different documentation systems like source-oriented records, problem-oriented records, nursing care plans, flow sheets, and computerized documentation.
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
This document discusses electronic medical records (EMRs) and patient record systems. It begins by defining an EMR as a digital medical record that allows clinicians to access patient data from any location. It then discusses the types of EMRs including departmental, inter-departmental, and hospital-wide systems. The document also covers electronic health records (EHRs), outlining their definition, structure, users, and components. Key aspects of medical records like purposes, principles of good record keeping, and characteristics of good recording are also summarized.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
Documentation-and-Reporting students sharing.pptAnju Kumawat
This document discusses documentation, recording, and reporting in healthcare. It covers the purposes of documentation which include communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing service records, and nursing education records. Guidelines are provided for recording, including principles of record writing, common record keeping forms, and computerized documentation. Methods of reporting include narrative charting and problem-oriented charting. The purposes of reporting to ensure communication among the healthcare team is also covered.
Maintenance of records and reports copySaurav Garg
This document discusses the importance of maintaining accurate and complete records in community health nursing. It outlines the purposes of records such as communication between healthcare providers, planning care, auditing health agencies, research, and education. The document describes different types of records including family records, anecdotal records, clinical records, doctors' order sheets, nurses' sheets, and registers. It provides guidelines for proper recording, including documenting date, time, legibility, permanence, accuracy, and use of accepted terminology. The value of records for nurses, families, doctors, and organizations is explained. Different reports used in community health settings are also outlined.
This document discusses documentation and reporting in healthcare. It covers the purposes of documentation such as communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing records, and academic records. It discusses guidelines for accurate, complete, confidential, and factual documentation. It also covers various types of reports like change of shift reports, transfer reports, and incident reports. The document provides examples of documentation forms and emphasizes the importance of minimizing legal liabilities through thorough documentation.
This document discusses documentation and reporting in healthcare. It defines documentation as communicating facts in writing over time to maintain a history of events. Recording and reporting are also forms of documentation. The purposes of documentation include communication, legal records, audits, research, education, and continuity of care. Different types of records are discussed, including patient records, nursing service records, and nursing education records. Principles of clear and accurate documentation are presented. The document also covers types of reporting, such as shift change reports and transfer reports.
Documentation and reporting in healthcare involves recording patient information in charts and providing communication to other healthcare professionals. Records can be either written or electronic and contain things like assessments, care plans, treatments, and test results. Reports convey information orally, in writing, or electronically and are used to communicate changes in a patient's condition between shifts or departments. Maintaining accurate documentation is important for continuity of care, legal purposes, reimbursement, and analyzing health outcomes. Proper communication between all members of the healthcare team through documentation and reporting is essential for providing comprehensive, high-quality patient care.
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.
Recording & Reporting is the content which explains about definition, Types, Principles, Purposes and role of nurse in Recording & reporting. It inlcudes practical application of nursing officers role.
Down syndrome is a genetic disorder caused by the presence of an extra chromosome 21. It is the most common chromosomal anomaly, occurring in about 1 in 800 to 1000 live births. People with Down syndrome often experience cognitive delays, characteristic facial features, and health issues such as congenital heart defects and thyroid problems. Treatment focuses on medical care, physical therapy, occupational therapy, and speech therapy to help patients develop skills and manage health conditions. Life expectancy has increased to 50-55 years with proper support and treatment.
Oxygen therapy involves administering oxygen at concentrations higher than in the air to treat low oxygen levels in the blood. It can be used for various conditions like respiratory failure, heart failure, and shock. Oxygen must be prescribed with the concentration, flow rate, and duration. It is delivered through various devices like nasal cannulas, oxygen masks, tents, and venturi masks. Safety precautions are needed as oxygen is flammable. Proper assessment, planning, and technique are required to administer oxygen therapy effectively and prevent complications like oxygen toxicity.
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.
This document discusses nursing records and reports. It defines records as permanent documentation of a client's health care and reports as summaries of services provided. Records are used to guide care, ensure continuity, and protect from legal issues. They must be factual, objective, dated, and signed. Reports are shared between caregivers and summarize services. Good reports are clear, concise, and prompt. The document outlines the types and importance of both nursing records and reports in hospital and community settings.
documentation and reporting for nursing students. this session deals with important of proper documentation and its legal implications, thus can reduce errors.
Dear all,
Recording & Reporting are very important in the nursing profession. As a nurse, we have to be very conscious of it to prevent further complications.
1) Nursing documentation is important for communication, accountability, and providing quality patient care. It involves recording all relevant information about a patient's condition, treatment, and the nursing care provided.
2) There are various methods of documentation, including traditional source-oriented records, problem-oriented records, and nursing process frameworks like PIE (Problem, Intervention, Evaluation) charting. Electronic health records are also increasingly common.
3) Proper documentation principles include recording objective factual information, using accepted terminology, keeping accurate and organized records, maintaining client confidentiality, and signing and dating all entries. Thorough documentation is essential for ensuring safe and coordinated care.
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.
The document discusses guidelines for effective nursing documentation. It outlines content, timing, format, accountability, and confidentiality guidelines. It also discusses the purpose of client records for communication, planning care, auditing, research, education, reimbursement, and legal documentation. Finally, it describes different documentation systems like source-oriented records, problem-oriented records, nursing care plans, flow sheets, and computerized documentation.
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
This document discusses electronic medical records (EMRs) and patient record systems. It begins by defining an EMR as a digital medical record that allows clinicians to access patient data from any location. It then discusses the types of EMRs including departmental, inter-departmental, and hospital-wide systems. The document also covers electronic health records (EHRs), outlining their definition, structure, users, and components. Key aspects of medical records like purposes, principles of good record keeping, and characteristics of good recording are also summarized.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
The document discusses principles and types of documentation in the ICU. It notes that documentation ensures continuity of care, provides legal protection, and records patient status, tests, treatments, and progress. Records must be written clearly, accurately, legibly, and in chronological order. Types of records include patient records, nurse and doctor notes, charts, intake/output records, and various logs. Records provide accurate information to guide care and have legal, educational, research, and administrative value. Proper care and storage of records is also outlined.
Documentation-and-Reporting students sharing.pptAnju Kumawat
This document discusses documentation, recording, and reporting in healthcare. It covers the purposes of documentation which include communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing service records, and nursing education records. Guidelines are provided for recording, including principles of record writing, common record keeping forms, and computerized documentation. Methods of reporting include narrative charting and problem-oriented charting. The purposes of reporting to ensure communication among the healthcare team is also covered.
Maintenance of records and reports copySaurav Garg
This document discusses the importance of maintaining accurate and complete records in community health nursing. It outlines the purposes of records such as communication between healthcare providers, planning care, auditing health agencies, research, and education. The document describes different types of records including family records, anecdotal records, clinical records, doctors' order sheets, nurses' sheets, and registers. It provides guidelines for proper recording, including documenting date, time, legibility, permanence, accuracy, and use of accepted terminology. The value of records for nurses, families, doctors, and organizations is explained. Different reports used in community health settings are also outlined.
This document discusses documentation and reporting in healthcare. It covers the purposes of documentation such as communication, legal records, audits, research, and education. It describes different types of records like patient records, nursing records, and academic records. It discusses guidelines for accurate, complete, confidential, and factual documentation. It also covers various types of reports like change of shift reports, transfer reports, and incident reports. The document provides examples of documentation forms and emphasizes the importance of minimizing legal liabilities through thorough documentation.
This document discusses documentation and reporting in healthcare. It defines documentation as communicating facts in writing over time to maintain a history of events. Recording and reporting are also forms of documentation. The purposes of documentation include communication, legal records, audits, research, education, and continuity of care. Different types of records are discussed, including patient records, nursing service records, and nursing education records. Principles of clear and accurate documentation are presented. The document also covers types of reporting, such as shift change reports and transfer reports.
Documentation and reporting in healthcare involves recording patient information in charts and providing communication to other healthcare professionals. Records can be either written or electronic and contain things like assessments, care plans, treatments, and test results. Reports convey information orally, in writing, or electronically and are used to communicate changes in a patient's condition between shifts or departments. Maintaining accurate documentation is important for continuity of care, legal purposes, reimbursement, and analyzing health outcomes. Proper communication between all members of the healthcare team through documentation and reporting is essential for providing comprehensive, high-quality patient care.
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.
Recording & Reporting is the content which explains about definition, Types, Principles, Purposes and role of nurse in Recording & reporting. It inlcudes practical application of nursing officers role.
Down syndrome is a genetic disorder caused by the presence of an extra chromosome 21. It is the most common chromosomal anomaly, occurring in about 1 in 800 to 1000 live births. People with Down syndrome often experience cognitive delays, characteristic facial features, and health issues such as congenital heart defects and thyroid problems. Treatment focuses on medical care, physical therapy, occupational therapy, and speech therapy to help patients develop skills and manage health conditions. Life expectancy has increased to 50-55 years with proper support and treatment.
Oxygen therapy involves administering oxygen at concentrations higher than in the air to treat low oxygen levels in the blood. It can be used for various conditions like respiratory failure, heart failure, and shock. Oxygen must be prescribed with the concentration, flow rate, and duration. It is delivered through various devices like nasal cannulas, oxygen masks, tents, and venturi masks. Safety precautions are needed as oxygen is flammable. Proper assessment, planning, and technique are required to administer oxygen therapy effectively and prevent complications like oxygen toxicity.
Child hospitalization involves admitting a child to the hospital for treatment, observation, or investigation. It can cause stress due to separation from family and an unfamiliar environment. Loss of control is also stressful, especially for younger children who rely on routines. Providing developmentally appropriate activities, maintaining routines when possible, encouraging independence, and promoting understanding can help minimize stress. The nurse aims to prevent separation when able and support the child's emotional needs.
This document discusses food adulteration, standards, and regulations. It defines food adulteration as the addition of non-permitted foreign matter or removal of ingredients from food. Food standards are set by experts and authorities to measure quality and ensure safety. The Codex Alimentarius Commission sets international food standards to protect health, educate consumers, and facilitate trade. National laws like the Prevention of Food Adulteration Act and Essential Commodities Act establish compulsory and voluntary standards in India.
Gastroenteritis, also known as infectious diarrhea and gastro, is inflammation of the gastrointestinal tract caused by bacteria, viruses or parasites. Common symptoms include diarrhea, vomiting and abdominal pain. It is generally a short-term, self-limiting condition but can lead to dehydration in infants and young children. Treatment involves oral rehydration with solutions containing electrolytes and sugars to replace fluid and minerals lost from diarrhea and vomiting. Antibiotics may be used in cases caused by bacteria. Prevention relies on proper hygiene including handwashing and drinking boiled water.
This document discusses food safety and storage. It explains that foods will deteriorate without proper preservation and identifies microorganisms like moulds, yeasts and bacteria as common causes of food spoilage. These microbes require certain conditions like warmth, moisture and time to grow. The document provides guidelines for food handling, storage and kitchen hygiene to prevent bacteria growth and food poisoning. It stresses keeping foods at proper temperatures, avoiding cross-contamination, thoroughly cooking foods and maintaining high standards of personal hygiene.
This document discusses imperforate anus, a birth defect where the anus is improperly developed such that stool cannot pass normally from the rectum. The etiology is unclear but genetic factors are involved. Diagnosis involves physical exam, radiological imaging, and other tests. Treatment involves initial colostomy if needed followed by anoplasty surgery to create an opening. Prognosis is generally good, especially for cases without additional defects.
Fats are more completely absorbed during pregnancy. Key nutrients important during pregnancy include protein, fatty acids like DHA and linoleic acid, calcium, iron, and vitamins. Nutritional recommendations include sufficient calories, iron, and other micronutrients from a variety of food sources. Maternal nutrition and weight factors can impact fetal development and health outcomes.
Renal failure is the inability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes. It can be acute or chronic. Acute renal failure causes a sudden, almost complete loss of kidney function that may be reversible. Chronic renal failure is a progressive, irreversible deterioration of renal function that eventually leads to end-stage renal disease if left untreated. Causes include prerenal issues like dehydration, intrarenal issues like toxicity or infection, and postrenal issues like obstruction. Both types damage nephrons, decrease glomerular filtration rate, and increase metabolic wastes in the blood and edema. Clinical manifestations include oliguria, electrolyte imbalances, edema, hypertension, and neurological
Complementary feeding should begin at 6 months of age when breast milk alone is no longer sufficient to meet nutritional needs. Signs a baby is ready include holding their head steady while sitting, opening their mouth when others eat, and appearing hungry soon after breastfeeding. Complementary foods should start liquid and gradually increase in consistency, while continuing frequent breastfeeding. A variety of nutrient-rich foods should be introduced slowly and hygienically to provide balanced nutrition as the baby grows.
- The document provides information on the importance of postnatal diet for new mothers through 12 points. It defines postnatal diet and discusses the benefits of adequate intake of folate, vitamin B12, iron, calcium, iodine, and vitamin D. Food sources for these nutrients are provided along with recommendations for daily intake. Tips are also given, such as taking supplements if certain food groups are avoided. The overall objective is to educate new mothers on postnatal nutrition.
Asthma is a chronic inflammatory disease of the airways characterized by airway hyperresponsiveness and reversible airflow obstruction. It is caused by a combination of genetic and environmental factors such as family history, prenatal sensitization, exposure to allergens and pollutants, and infections. Asthma is classified based on severity from mild to severe. Symptoms include wheezing, coughing, chest tightness, and shortness of breath. Diagnosis involves assessing symptoms and lung function tests. Treatment focuses on bronchodilators and inhaled corticosteroids to prevent symptoms and exacerbations.
Cleft lip and palate is an abnormal separation of tissues in the oral-facial region that occurs during fetal development. It can be caused by genetic factors, viruses, or other toxins. Symptoms include separation of the lip or palate, nasal distortion, ear infections, feeding difficulties, and speech and dental problems. Treatment involves surgery to repair the cleft, as well as speech therapy and orthodontics. Surgical repair of the cleft lip is usually done at 3-9 months of age, while cleft palate repair is typically between 18-24 months. Non-surgical treatments like dental obturators may also be used. Nursing care focuses on safe feeding and preventing aspiration during intake.
An NG tube is placed in the nose or mouth and passed into the stomach to feed babies and children who cannot eat enough by mouth. The document provides instructions on preparing, placing, securing, checking placement of, and feeding/cleaning an NG tube. It describes marking the tube to measure insertion depth and lubricating the tip before slow insertion. Placement must be checked before each feeding by withdrawing stomach contents or looking for signs of distress. The feeding is given slowly over 15-20 minutes and the tube is cleaned after use.
This document provides guidelines for expressing breast milk by hand and feeding infants using a spoon or paladai. It describes the proper technique for expressing breast milk, including hand washing, positioning, breast compression, and alternating between breasts. It also outlines how to feed infants with a spoon or paladai, including proper utensil cleaning, baby positioning, slow milk delivery, and burping. The document emphasizes the importance of frequent milk expression and provides tips for adequate milk production and storage.
This document discusses appendicitis, including its definition, causes, symptoms, diagnosis, treatment options, nursing care, and complications. Appendicitis is inflammation of the appendix that most commonly affects the pediatric population. The cardinal signs of appendicitis are abdominal pain that starts around the navel and later localizes to the lower right abdomen, nausea, vomiting, anorexia, and tenderness in the lower right abdominal quadrant. Treatment involves medical management with antibiotics or surgical removal of the appendix via open or laparoscopic appendectomy.
Intestinal parasites like roundworm, whipworm, and hookworm infect the small intestines of humans and can cause nutritional deficiencies. Common symptoms include abdominal pain, diarrhea, and fatigue. Parasites are typically transmitted by ingesting food or water contaminated with parasite eggs or through skin contact. Treatment involves antibiotics, antiparasitic medication like albendazole, and improved hygiene practices to prevent transmission.
This document provides information on infant radiant warmers and incubators. It discusses their purpose of maintaining an infant's body temperature, modes of operation including servo and manual, parts, indications for use, differences between the two devices, and care procedures. The key points are that radiant warmers and incubators are overhead heating units that help regulate an infant's temperature through radiant heat or enclosed warm air, but radiant warmers allow for greater access while incubators provide more controlled humidity and temperature. Proper use and monitoring are important for safely maintaining an infant's thermal needs.
This document discusses intestinal obstruction in pediatric patients. It outlines three types of intestinal obstruction: mechanical, paralytic ileus, and strangulation obstruction. The document also covers risk factors, clinical manifestations, diagnostic evaluation, treatment options including nonsurgical and surgical management, potential complications, and the roles of nursing in assessment, diagnosis, and interventions.
This document outlines the essential equipment needed for newborn resuscitation and stabilization. It includes items for temperature maintenance like warmed towels and blankets; suction equipment like bulb syringes and suction catheters; oxygen supplies and flow meters; monitoring tools like stethoscopes and pulse oximeters; resuscitation devices like bags and masks; intubation equipment; gastric decompression tubes and syringes; intravenous access items; tape and bandages; drug administration syringes and needles; and emergency medications and fluids. The goal is to have a fully stocked and organized resuscitation area prepared to stabilize any newborn in need of support.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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2. • Documentation and reporting
• · Documentation – purposes of reports and records
• · Confidentiality
• · Types of client records/common record keeping forms
• · Methods/systems of documentation/recording
• Guidelines for documentation
• · Do‘s and don‘ts of documentation/legal
• · Reporting – change of shift reports,
• Transfer reports, incident reports
3. • DOCUMENTATION serves as a permanent record of client information and care.
• Reporting takes place when two or more people share information about client care, either face
to face or by telephone
4. PURPOSES
• Communication. Provides efficient and effective method of sharing information.
• Legal documentation. It is admissible as evidence in a court of law.
• Research. Provides valuable health-related data for research.
• Statistics. Provides statistical information that can be utilized for planning people’s future needs.
• Education. Serves as an educational tool for students in health discipline.
5. • Audit & quality assurance. Monitors the quality of care received by the client and the competence
of health care givers.
• Planning client care. Provides data which the entire health team uses to plan care for the client.
• Reimbursement. Provides the basis for decisions regarding care to be provided and subsequent
reimbursement to the agency, to cover health-related expenses
6. TYPES OF RECORD
• Source oriented medical record
• Each person or department makes notations in a separate section/s of the client’s chart.
• Most traditional
• Different disciplines chart on separate forms
• each reader must consult various parts of the record to get a complete picture
• Records become bulky
7. NARRATIVE CHARTING ( TRADITIONAL CLIENT RECORD )
• ▫ Most flexible of all methods and is usable in any clinical setting.
• • Five basic components of a traditional client record
• admission sheet
• physician’s order sheet
• medical history
• nurse’s notes
• special records and reports (referrals, x-ray, reports, laboratory findings, report of surgery, anest hesia
record, flowsheets, vital signs I&O, medications)
8. PROBLEM-ORIENTED MEDICAL RECORD
(POMR OR POR)
• The record integrates all data about the problem, gathered by the members of the health team.
• Four basic components of POMR /POR
• database.
• Problem list.
• Initial list of orders or care plans.
• Progress notes:
Nurse’s or narrative notes (SOAPIE format) subjective, objective, analysis, planning, intervention, evaluation
• ◦ flow sheets (data that are monitored)
• ◦ discharge notes or referral summaries
10. A. NURSE’S OR NARRATIVE NOTES (SOAPIE
FORMAT)
• S-subjective. What pt tells you.
• 0 – objective. What you observe, see.
• A – assessment. What you think is going on based on your data.
• P – . plan what you are going to do. Can add to better reflect nursing process
• i – intervention (specific interventions implemented)
• e – evaluation. Pt response to interventions.
• R – revision. Changes in treatment.
11. B. PIE CHARTING
• Similar to SOAP charting
• both are problem-oriented
• PIE comes from the nursing process, SOAP comes from a medical model.
• P-problem
• i-intervention
• e-evaluation ex:
• p#1 risk for trauma related to dizziness. •
IP#1 instructed to call for assistance when getting OOB. Call light in reach.
• EP#1 consistently call for assistance before getting OOB. Continues to experience dizziness.
12. C. FOCUS CHARTING
• Uses narrative documentation (dar)
• data – subjective or objective that supports the focus (concern)
• action – nursing intervention
• response – pt response to intervention
Ex:
• D – complaining of pain at incision site , ps: 7/10
• A – repositioned for comfort. Demerol 50mg im given.
• R – states a decrease in pain, “feels much better.”
13. D. COMPUTERIZED CHARTING
• Password. Never share or change frequently.
• Legible
• can be voice-activated, touch-activated.
• Date and time automatically recorded.
• Abbreviations and terms are selected by a menu provided by the facility.
• Terminals are usually easily accessible, in pt rooms, convenient hallway locations.
• Make sure terminal cannot be viewed by unauthorized persons.
14. KARDEX
• Provides a concise method of organizing and recording data about a client, making information
readily accessible to all members of the health team
• It is a series of flip cards usually kept in portable file
• it is a way to ensure continuity of care from one shift to another and from one day to the next
• It is a tool for change – of – shift report. But endorsement is not simply reciting content of
kardex. Health care needs of the client is still primary basis for endoresement.
15. CONTD…
• Usually include the ff. Data:
– personal data
– basic needs
– allergies
– diagnostic tests
– Daily nursing procedures
– medications and intravenous (IV) therapy, blood transfusions
– treatments like oxygen therapy, steam inhalation, suctioning, change of dressings, mechanical
ventilation.
• Entries usually written in pencil. This implies the kardex is for planning ang communication
purpose only.
16. General Documentation Guidelines
• Ensure that you have the correct client record or chart.
• Document as soon as the client encounter is concluded to ensure accurate recall of data.
• Date and time of each entry.
• Sign each entry with your full legal name and with your professional credentials.
• Do not leave space in between entries.
• If an error is made while documenting, use a single line to cross out the error, then date, time and sign
the correction
• Never change another person’s entry even if it is incorrect
• Use quotation marks to indicate direct client responses.
• Document in chronological order
• Use permanent ink
• document all telephone calls that you received that are related to client’s case.
17. Characterstics of Good Recording
Brevity
• Entries are concise
• Complete sentences are not required
• Start each entry with a capital letter and end the entry with a period even if the entry is a single word
or phrase.
Use ink/permanence
• Avoid pencil for permanence of data, because the client’s chart can be used as an evidence in a legal
court.
18. CONTD…
Accuracy
• chart objective facts, not your interpretations or opinions
Eg.
• Ate 50% of the food served not ate with poor appetite.
• Refused medications not uncooperative.
• Seen crying not depressed.
19. • Place complaint of the client in quotation marks to indicate that it is his statement. “Chest pain
radiating down the left arm”
• objective data are also to be charted.
E.G. Skin cold and clammy. Diaphoretic. Prefers to sit up. Vital signs taken as follows: temp-37.6C,
PR-110/min., RR-26/min. BP-140/90 mmhg.
• Describe behaviors rather than feelings to allow other health team members to determine the
actual problems of the client.
• Refusal of medications and treatments must be documented.
20. CONTD…
Appropriateness
• only information that pertains to the client’s health problems and care are recorded.
• Any other personal information that is conveyed to the nurse is appropriate for the record.
21. CONTD…
Completeness and chronology/organization/sequence/timing.
• Notes should appear on each succeeding line
• Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new
idea or entry.
• Date is entered in the date column on the first line of every page of nurse’s notes and whenever the date
changes.
• Time is entered in the time column whenever a new time entry occurs.
• Avoid time changes in the text of nurse’s notes.
• Avoid double chart. If something appears on a particular sheet, it does not need to appear on the nurse’s
notes, unless there is an alternation from the normal, e.G. Body temperature, blood pressure.
• Avoid squeezing information to a space because you forgot to chart it earlier. Add the information on the
first available line. Write the time the event occurred, not the time you entered the information.
22. • The following information should be charted:
Physician’s visits.
Times the patient leaves and returns to the unit, mode of transportation and destination.
Medications should be charted immediately after administration. O treatments should be charted immediately
after being done.
Use of standard terminology
Use only those abbreviations and symbols approved by the institution; spell correctly, use proper grammar.
Signed.
Affix signature, place at the end of charting, at the right hand margin of the nurse’s notes. Sign each entry with
your full name and status, e.g. SN for student nurse, RN for registered nurse. Script, not printing is used for the
signature.
23. • Confidentiality
Only the health personnel who participate in the care of the client are allowed to read the chart.
• Legal awareness
Chart only what you personally have done, observe, heard, smelled, or felt.
Do not discard any of the client record.
• Legible
Writing must be clear and easily read by others
If writing is not legible, then print.
A horizontal line drawn to fill up a partial line. This is to prevent other persons from adding information
in the nurse’s notes.
Eg. Needs attended. Referred accordingly.-------Ma. Tosca cybil torres, RN, MAN
24. REPORTING
• Takes place when two or more people share information about client care , either face to face or
by telephone.
Types of reporting
• Walk in rounds
• change – of – shift reports or endorsement – for continuity of care – it is based on health care
needs of the client – it is not mere reciting the content of the kardex
25. Telephone reports
Provide clear accurate and concise information
the nurse documents telephone report by including the following information:
• when the call was made
• who made the call/report
• who was called
• to whom information was given
• what information was given
•what information was received
26. • Telephone orders
• only RN’s may receive telephone orders
• the order need to be verified by reporting it clearly and precisely.
• The order should be countersigned by the physician who made the order within the prescribed period of
time (within 24 hours)
transfer reports – this is done when transferring a client from unit to another.
Incident reports or occurrence reports – used to document any unusual occurrence or accident in the
delivery of client care
27. GROUP ACTIVITY SITUATION :
• Antonioayo farmer was , 55 / , found by his son lying on the floor unconscious.
• He was brough to the ER and was diagnosed with CVA probably, bleeding he is then admitted to the medical ICU
for continuity of critical care he is drowsy, restless at times severely , dyspneic and wit h excessive, secretins
• Crackles are heard upon auscultation at both lower lung fields .
• Vital Signs
• B P . / : 19 0 /110 , 3 9 , m m H g
• T ° 39°C
• Respiratory Rate 38 per minute ,
• Pulse Rate 112 bats per minute