Why is there a need for nursing documentation
Good record keeping promotes
Who reads nursing records
What is expected of a registered nurse
Record keeping should demonstrate
Nurses accountability
Legal Matters of Nursing Record's
Why is there a need for nursing documentation
Good record keeping promotes
Who reads nursing records
What is expected of a registered nurse
Record keeping should demonstrate
Nurses accountability
Legal Matters of Nursing Record's
Admission process of client in hospital
- types of admission
- process of admission
- preparation of unit
- tranfer procedure
- role of nurse in admission
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.
Admission process of client in hospital
- types of admission
- process of admission
- preparation of unit
- tranfer procedure
- role of nurse in admission
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.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. GENERAL OBJECTIVE
Define documentation
Enlist Purpose of documentation
Types of documentation
Explain Documentation System
Do And Don’t
Discuss Forms Of Documentation
Nurse’s Responsibilities In Documentation
4. Purpose Of Documentation
Communication
Education
Legal Document
Quality Assurance
Research
Nursing Audit
Health Care Analysis
5. Types Of Documentation
1. Recording
2. Charting
Recording- Is a brief account of the personal history,
medical history, results of diagnostic tests, findings in
physical examination, treatment and nursing care,
Progress notes and condition on discharge.
6. Charting- Is a permanemt, written and complete record
of the health history and sociological information obtained
from a person admitted to a hospital by listening to him,
looking at him and treating him.
7. Documentation System
1. Source-Oriented Record.
2. Problem-Oriented Medical Record (POMR).
3. Problem, Itervention, Evaluation (PIE).
4. Focus Charting.
5. Charting by exception (CBE).
6. Computerized documentation and care management.
8. • Source-Oriented record- Source-oriented is a narrative
Recording by each member of the health care team on
separate documents.
• Problem-oriented Medical Record- (POMR) are
organized
around the client’s problem. It employs a structured, logical
format, Which focuses on the client’s problem.
9. • Problem, Intervention, Evaluation- PIE is an
acronym for problems,intervention and
evaluation of nursing care this system was
to develop streamline documentation.
• Focus Charting- highlights the client’s concerns,
problems or strengths. Is a documentation
System using column to format data.
10. • Charting by exception (CBE)- Is a documentation in which only
abnormal or significant finding or exceptions to norms are
recorded. CBE uses pre-printed flow sheets to document the most
aspects of care.
• Computerized documentation- Computers make care planning and
Documentation relatively easy. Nurses use computers to store the
client database, add progress.
11. Do’s and Do Not’s
Do’s
Use objective, specific and factual description
Correct the charting errors
Chart all teaching
Review your notes
Do support medical necessity
12. Do Not's
• Leave blank space for a colleague to chart later
• Chart in advance of the event
• Use vague terms
• Chart for someone else
• Use patient or client as it is in the chart
• Alter a record, even if requested by a physician
• Record assumption or a word reflecting bias
13. Forms Of Documentation
• Kardexes- Is a concise method of organizing and recording
data about a client, making information quickly accessible to
all health professional. It contains- Client information, list of
medical diagnosis on priority, allergies, list of daily treatments,
procedures and measurement of vital signs, procedure order
Such as X-ray and lab tests.
14. • Flow Sheets- A simple form that gathers all important
data regarding a patient’s condition it includes graphic
records, medication administration record, etc.
• Progress Notes- Is the notes made by nurses provided
information about the progress a client is making
towards Achieving desired outcome.
15. • Discharge Summary- Is completed when the patient
is being discharged and refered to home. It includes:
Client instructions about medication, diet, food-drug
Interaction, etc.
16. Nurse’s Responsibilities In Documentation
• Should keep under safe custody of nurses.
• No individual sheet should be separated.
• Not accessible to patients and visitors.
• Strangers is not permitted to read records.
• Errors in nursing charting must be corrected
Promptely in a manner that leaves no doubts
About the facts.
17. Summary
Today we have discussed about
• Types of documentation
• System of documentation
• Do and Do not’s
• Forms of documentation
• Nurse‘s responsibilities in documentation
18. Conclusion
Documentation is the act of recording client’s status
and care in the written form. Client records are legal
documents that provide evidence of a client’s Care.
Examples of documentation system include PIE,
focus charting, charting by exception (CBE),
computerized documentation and case management.
19. Questions
1. Define documentation.
2. Enlist the purposes of Documentation.
3. What are the types of documentation?
4. Explain uses of documentation systems.
5. What are the nurse’s responsibilities in documentation
20. Reference
• Nursing Foundation Jaypee.
Author- BT basavanthappa
• Nursing Foundation- 3rd edition
Author- I Clement
• Jems.com