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| legal guidelines for recording 1-10 |
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Definition
| do not erase, no personal opinions, correct promptly, factual recording, black ink, no blank spaces, note clarified orders, chart for self only,no generalized phrases, military time, protect password |
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| factual, accurate, complete, current, organized, confidential |
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| subjective- objective- assessment- plan |
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| problem- intervention- evaluation |
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| focuses on deviations from the norm |
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| NOT a legal document- can use a pencil and erase |
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| to fix error in recording |
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Definition
| draw a single line thru error, write "error" above it and sign, date, time |
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| to record patient comments |
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| common reports given by nurses |
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| change-of-shift reports, telephone reports, hand-off reports, incident reports |
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Term
| nurses must meet the minimum standard of care |
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Definition
| for every task they perform |
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Term
| who has legitimate access to pt records? |
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Definition
| only staff directly involved w that pt. |
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| staff may not discuss what w other staff? |
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Definition
| examination, observation, conversation, diagnosis, or treatment of their pts. |
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| current documentation standards require that all pt have what kind of assessments? |
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Definition
| physical, psychosocial, environmental, self-care,knowledge level, and discharge planning. |
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