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.
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.
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.
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.
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 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 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.
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.
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.
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.
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.
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.
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 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 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.
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.
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 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 discusses guidelines for nursing documentation. It emphasizes that documentation is an integral part of nursing practice and is necessary for efficient patient care, communication, legal and professional standards, education, and quality improvement. Some of the key guidelines covered include documenting objectively and factually, timely completion of records, following guidelines for corrections, recording patient education, and incident reporting. Thorough and accurate documentation is essential for nursing accountability and high quality patient care.
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 & 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.
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.
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.
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.
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.
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.
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.
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.
Medical records document a patient's medical history and are important for continuity of care, defending malpractice claims, research, and more. A medical record chronicles a patient's examinations, treatments, test results, medications, and other details. It benefits patients by facilitating further treatment, and benefits doctors, hospitals, and other professionals by allowing them to continue care where others left off. Key characteristics of good medical records include accuracy, completeness, timeliness, and authentication. Issues can include deficiencies, legal and ethical concerns, and challenges maintaining outdated or inactive records.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
This document discusses the principles and purposes of EMS documentation. It emphasizes that the prehospital care report (PCR) is the sole written record of an ambulance call and should include both narrative and check-box sections. The PCR is used for medical, administrative, research, and legal purposes. Special situations like patient refusals, non-transport calls, and mass casualty incidents require specific documentation approaches. Proper documentation is important for patient care, legal protection, and system improvement.
Computer technology has been used in nursing documentation since the 1960s. Accurate documentation in medical records is critical for proper patient treatment and recovery. Records provide a permanent record of a patient's care and treatment, and support continuity of care between providers. Computers now play a vital role in hospitals by facilitating electronic patient record systems, which collect, store, and make clinical information easily accessible to support efficient patient care and treatment.
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.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Communication of Research Findings .pptxArvind joshi
The document discusses various aspects of communicating nursing research findings. It describes the importance of disseminating research findings for evidence-based practice. Some key methods discussed include publishing in journals or books, conference presentations, and poster presentations. It provides guidance on selecting publication outlets, developing manuscripts, common barriers, and ensuring ethical standards in research dissemination.
This document outlines skills for health care workers to effectively counsel mothers on breastfeeding. It discusses the importance of: using active listening skills like maintaining eye contact and asking open-ended questions; accepting what mothers say without judgment; praising mothers for what they do right to build confidence; providing practical help rather than just information; giving relevant information and checking for understanding; using simple language; and making suggestions instead of commands to empower mothers' choices. The overall aim is for health workers to understand mothers' perspectives and support them in confidently breastfeeding.
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 discusses guidelines for nursing documentation. It emphasizes that documentation is an integral part of nursing practice and is necessary for efficient patient care, communication, legal and professional standards, education, and quality improvement. Some of the key guidelines covered include documenting objectively and factually, timely completion of records, following guidelines for corrections, recording patient education, and incident reporting. Thorough and accurate documentation is essential for nursing accountability and high quality patient care.
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 & 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.
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.
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.
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.
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.
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.
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.
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.
Medical records document a patient's medical history and are important for continuity of care, defending malpractice claims, research, and more. A medical record chronicles a patient's examinations, treatments, test results, medications, and other details. It benefits patients by facilitating further treatment, and benefits doctors, hospitals, and other professionals by allowing them to continue care where others left off. Key characteristics of good medical records include accuracy, completeness, timeliness, and authentication. Issues can include deficiencies, legal and ethical concerns, and challenges maintaining outdated or inactive records.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
This document discusses the principles and purposes of EMS documentation. It emphasizes that the prehospital care report (PCR) is the sole written record of an ambulance call and should include both narrative and check-box sections. The PCR is used for medical, administrative, research, and legal purposes. Special situations like patient refusals, non-transport calls, and mass casualty incidents require specific documentation approaches. Proper documentation is important for patient care, legal protection, and system improvement.
Computer technology has been used in nursing documentation since the 1960s. Accurate documentation in medical records is critical for proper patient treatment and recovery. Records provide a permanent record of a patient's care and treatment, and support continuity of care between providers. Computers now play a vital role in hospitals by facilitating electronic patient record systems, which collect, store, and make clinical information easily accessible to support efficient patient care and treatment.
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.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
Communication of Research Findings .pptxArvind joshi
The document discusses various aspects of communicating nursing research findings. It describes the importance of disseminating research findings for evidence-based practice. Some key methods discussed include publishing in journals or books, conference presentations, and poster presentations. It provides guidance on selecting publication outlets, developing manuscripts, common barriers, and ensuring ethical standards in research dissemination.
This document outlines skills for health care workers to effectively counsel mothers on breastfeeding. It discusses the importance of: using active listening skills like maintaining eye contact and asking open-ended questions; accepting what mothers say without judgment; praising mothers for what they do right to build confidence; providing practical help rather than just information; giving relevant information and checking for understanding; using simple language; and making suggestions instead of commands to empower mothers' choices. The overall aim is for health workers to understand mothers' perspectives and support them in confidently breastfeeding.
This document provides information about central venous catheters and PICC lines, including their indications, contraindications, anatomy, insertion procedures, complications, and care. It discusses the internal jugular, subclavian, and femoral vein access sites and provides details on the Seldinger technique for catheter insertion. The roles of nurses in central line care including dressing changes, flushing, and preventing infections are also covered.
Medical records provide essential patient information to assist in their care. They should identify the patient, be legible, accurate, organized, and promptly retrievable. Records are used for patient care, research, insurance reimbursement, and legal cases. In India, record-keeping became mandatory in 2002. The government is promoting digital health initiatives like electronic medical records and personal health records. Records must be maintained according to regulatory standards on preparation, preservation, and length of storage, with some exceptions for minors or ongoing legal cases.
The document discusses patient classification systems (PCS), which categorize patients based on their nursing care needs. PCS help determine appropriate staffing levels and skill mix. Several types of PCS are described, including functional status, severity of illness, nursing intensity, and diagnosis-related groups systems. PCS assess factors like activities of daily living, medical conditions, treatments required, and nursing interventions needed. Accurately classifying patients improves workforce management, care planning, and outcomes. Ongoing training and adapting to changing patient needs are important challenges for effective PCS implementation.
Telemedicine is defined as the delivery of healthcare services using telecommunications technology when distance is a factor. There are three main types: store-and-forward, remote monitoring, and interactive services. Telemedicine provides benefits to patients like reduced costs and travel, and benefits healthcare systems by improving access and reducing unnecessary visits and hospitalizations. However, there are also barriers to telemedicine like physician and patient acceptance of technology, high costs, unreliable infrastructure, lack of trained professionals, and privacy/legal concerns.
The document summarizes a seminar on the skeletal system presented by Mr. Arvind Joshi. It covers the embryology, anatomy, physiology and classification of bones. It also discusses diagnostic criteria and common medical treatments for skeletal issues like fractures, club foot, congenital hip dysplasia, osteomyelitis, and polydactyly/syndactyly. Nursing management is outlined for various conditions and treatments involving casting, traction, splinting and bracing. Recent advances in treating skeletal issues are also mentioned.
This document discusses protein-energy malnutrition (PEM). It defines PEM as a clinical syndrome in infants and children resulting from deficient intake and utilization of food. PEM is classified using several systems including Gomez, Wellcome Trust, WHO, and IAP classifications based on weight, height, and age indicators. PEM has multiple risk factors and etiologies related to poverty, infections, feeding practices, and social factors. The clinical manifestations of PEM include kwashiorkor and marasmus. Treatment focuses on beginning feeding, providing energy dense foods, stimulating development, and transferring to home-based diets. Prevention strategies include growth monitoring, breastfeeding, immunization, and addressing underlying social determinants.
The document discusses the management of respiratory disorders in children. It begins with the anatomy and functions of the respiratory system. It then discusses diagnostic procedures for respiratory disorders and various respiratory therapies. The document further discusses disorders of the upper respiratory tract including common cold, tonsillitis, laryngitis, and croup. It also discusses disorders of the lower respiratory tract such as bronchitis. Treatment options for various respiratory conditions are provided.
Aseptic technique involves strict practices and procedures to prevent contamination from pathogens during medical procedures. It aims to minimize the risk of infection transmission. Healthcare workers follow aseptic technique in surgery rooms and clinics to protect patients from harmful bacteria. The key principles of aseptic technique include thorough hand hygiene, maintaining a sterile environment and equipment, properly wearing protective equipment, and avoiding touching sterile surfaces. Following aseptic technique helps prevent healthcare-associated infections in patients.
Guillain-Barre syndrome is an autoimmune disorder where the immune system attacks the peripheral nervous system, causing demyelination of nerves. It can affect motor, sensory and autonomic functions. Risk factors include recent infections. Diagnosis involves electromyography, nerve conduction tests and lumbar puncture showing elevated proteins. Symptoms vary but can include limb weakness and sensory abnormalities. Treatment focuses on immunotherapy like IVIG or plasmapheresis in early stages as well as supportive care. Most patients recover fully but some have residual deficits.
The document discusses endocrine disorders and focuses on diabetes mellitus and thyroid disorders. It defines diabetes mellitus as a group of metabolic diseases involving high blood sugar levels over a prolonged period. The main types of diabetes are type 1, type 2, and gestational diabetes. Type 1 results from the pancreas failing to produce insulin, while type 2 involves insulin resistance and sometimes a lack of insulin. Gestational diabetes occurs during pregnancy. The document also discusses the thyroid gland, which produces hormones that regulate growth, development and metabolism. Common thyroid disorders are then discussed.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Hiranandani Hospital in Powai, Mumbai, is a premier healthcare institution that has been serving the community with exceptional medical care since its establishment. As a part of the renowned Hiranandani Group, the hospital is committed to delivering world-class healthcare services across a wide range of specialties, including kidney transplantation. With its state-of-the-art facilities, advanced medical technology, and a team of highly skilled healthcare professionals, Hiranandani Hospital has earned a reputation as a trusted name in the healthcare industry. The hospital's patient-centric approach, coupled with its focus on innovation and excellence, ensures that patients receive the highest standard of care in a compassionate and supportive environment.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
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
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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
2. Documentation & reporting in Nursing
• Documentation is the professional responsibility of all health care practitioners.
• Its provides a system of written records that reflect client care provided on the
basis of assessment data and the client’s response to interventions.
• Effective documentation requires clear, concise, accurate recording of all client care
and other significant events in an organized and chronological fashion.
• Nurses are bound by ethical codes and laws to treat all client information in a
confidential and professional manner.
3. Documentation is defined as written evidence of:
• The interactions between and among health professionals,
clients, their families, and health care organizations.
• The administration of tests, procedures, treatments, and client
education.
• The results or client’s response to these diagnostic tests and
interventions
5. Reporting
• is the oral, written, computer based communication intended to convey data regarding the
client’s (health status, needs, treatments, outcomes, and responses) to others health team
members.
6. Functions of Reporting
• helping to improve accountability
• showing how decisions related to patient care were
made
• supporting the delivery of services
• supporting effective clinical judgements and
decisions
• supporting patient care and communications
• making continuity of care easier
• providing documentary evidence of services
delivered
• promoting better communication and sharing of
information between members of the multi-
professional healthcare team
• helping to identify risks, and enabling early
detection of complications
• supporting clinical audit, research, allocation of
resources and performance planning, and
• helping to address complaints or legal processes
7. Purposes of Documentation:
Professional responsibility and accountability.
Communication,
Care planning,
Decision analysis
Education,
Research, auditing or statistics.
Meeting legal and practice standards,
Reimbursement.
8. Principles of effective documentation:
• Nursing notes must be logical, focused, and relevant to care, and must represent each phase in
the nursing process. Documentation requirements will differ depending on:
• a. Health care facility (hospital, nursing home, home health agency).
• b. Setting within the facility (e.g., emergency room, medical-surgical unit).
• c. Client populations (e.g., obstetrics, pediatrics, geriatrics).
9. Elements of Effective Documentation:
• Effective documentation requires:
• 1. Use of a common vocabulary (Proper use of spelling and grammar).
• 2. Identify the client, and write in ink.
• 3. Legibility and neatness.
• 4. Use of only authorized abbreviations and symbols. (ABG, ca, BSA, CABG, bpm, CBC, CPAP,
D5W)
• 5. Factual and time-sequenced organization.
• 6. Accurately including any errors that occurred.
10. 1. Use of Common Vocabulary:
• Nursing practice reflects the use of multiple terms for nursing interventions, preventing cross
institutional comparisons of nursing care.
• The current efforts under way to establish a taxonomy for nursing interventions determined by
specific nursing diagnoses will enhance the quality of documentation and support the efforts of
researchers.
• Use of common vocabulary will also improve intra team communication and lessen the chance
of misunderstandings
11. 2. Identify the client, and write in ink:
• every page of client record should have the client name on it. And every document, information
should be charted in ink or print out from computer.
12. 3. Legibility:
• Whatever is charted must be easily readable, without any chance of error.
• If your handwriting is not readable, print. If you make a mistake, do not erase or obliterate it;
draw one line through the erroneous entry and state the reason for the error, then sign and date
the correction.
13. 4. Abbreviations and Symbols:
• Facilities usually have a list of acceptable abbreviations and symbols, approved by the Medical
Records Committee, to be used when documenting information in the client’s record.
• Avoid abbreviations that can be misunderstood
14.
15.
16. 5. Factual and time-sequenced organization:
• a. Start every entry with the date and time.
• b. Chart in a chronological order assessment data, observation, intervention, and evaluation.
• c. Comply with the time frame indicated in the facility’s guidelines for documentation: for
example, the frequency of charting observations for a client with restraints or the time frame
within which the admit assessment must be completed.
• d. Chart in a timely fashion to avoid the omission of data; it is not a good practice to wait until
the end of the shift to chart on all the clients.
• e. Chart medications immediately after administration to avoid errors.
• f. Sign your name after each entry.
• g. When the nurse forgets to document significant data, it is appropriate and advisable to
include these data at a later date.
17. 6.Accuracy:
• Accuracy and objective data are crucial if the documentation is to be useful either clinically or
for research. Use factual, descriptive terms to chart exactly what was observed or done; for
example use correct spelling and grammar, and write complete sentences.
18. Types of Records
1. Patients Clinical Records
It is the record of events in the patient illness, progress in his or her
recovery and the type of care given by the hospital personnel.
2. Individual staff records.
A separate set of record is needed for staff, giving details of their
absences, their carrier development activities and a personnel note.
I
19. 3. Ward Records
These records are maintained in the each ward, such as
Census records.
Change in medical staff and non nursing personnel for the ward. (Duty roaster)
Inventory and stock records
Staffs Leave records
Admission records
Transfer records
Discharge records
Medicine records etc.
20. 4. Administrative records
These records are maintained purely for administrative purpose of the hospital or unit
Legal documents: for the patients with poisoning, assault, rape, burns etc.
Research or statistics data records
Audit and nursing audit records
Quality of care records
Personnel performance. records
Other administrative records
21. Type of reports
• 1. Change of shift reports
• A change of shift reports is given by a primary nurse to the nurse who assumes responsibility for
continuing care of the patient. The change of shift report might be given in written form or
orally.
• It provides basic identifying information such as patient condition, current appraisal of
each patients’ health status, current order by the physician, changes of medication,
intravenous fluids, diet, activity level.
Summary of each newly admitted patient.
Report on patients who have been transferred or discharged.
22. • 2. Transfer Report
• Transfer reports are provided by nurses when transferring a patient to another unit or to another
Ward/Hospital. Transfer reports contain similar information as bedside handoff reports, but are
even more detailed when the patient is being transferred to another Ward/Hospital.
23. • 3.Incident Report
• Incident reports, or sometimes called incident reporting, unusual occurrence report, or variance report;
is a commonly used term to describe safety event reporting. A safety event can occur when evidenced-
based best practice isn’t followed, resulting in harm or potential harm to a client.
• Some examples of safety events include accidental needlesticks, falls, medication errors which are the
number one cause of incidents, defective systems or equipment failure, missing client belongings
belongings and hospital acquired infections. Usually, an incident report is generated from the healthcare
healthcare worker.
24. Don’ts of documentation
o Leave a blank space for colleague to chart later
o Chart in advance of the event (procedure, medication)
o Use vague term
o Chart for someone else
o Record patient because its in their chart
o Skip a record even if requested by a supervisor
o Never guess about what is written.
25. Privacy and confidentiality
• All patients have a right of privacy and confidentiality
• All information about patient is considered private or confidential
26. General Documentation Guidelines:
Ensure that you have the correct client record or chart and that the client’s name and identifying
information are on every page of the record.
Document as soon as the client encounter is concluded to ensure accurate recall of data (follow
institutional guidelines on frequency of charting).
Date and time each entry.
Sign each entry with your full legal name and with your professional credentials, or per your
institutional policy.
Do not leave space between entries.
27. If an error is made while documenting, use a single line to cross out the error, then date, time,
and sign the correction (check institutional policy); avoid erasing, crossing out, or using
correction fluid.
Never change another person’s entry, even if it is incorrect.
Use quotation marks to indicate direct client responses (e.g., “I feel lousy”).
Document in chronological order (if chronological order is not used, state why).
Write legibly.
28. Use a permanent-ink pen (black is usually preferable because of its ability to photocopy well).
Document in a complete but concise manner by using phrases and abbreviations as
appropriate.
Document all telephone calls that you make or receive that are related to a client’s case.
29. Assessment-Specific Documentation
Guidelines
1. Record all data that contribute directly to the assessment (e.g., positive assessment findings
and pertinent negatives).
2. Document any parts of the assessment that are omitted or refused by the client.
3. Avoid using judgmental language such as “good,” “poor,” “bad,” “normal,” “abnormal,”
“decreased,” “appears to be,” and “seems.”
4. Avoid evaluative statements (e.g., “client is uncooperative,” “client is lazy”); cite instead
specific statements or actions that you observe (e.g., “client said ‘I hate this place’ and kicked
trash can”).
30. 5. State time intervals precisely (e.g., “every 4 hours,” “bid,” instead of “seldom,” “occasionally”).
6. Do not make relative statements about findings (e.g., “mass the size of an egg”) use specific
measurement (e.g. “mass 3cm )
7. Draw pictures when appropriate (e.g., location of scar, masses, skin lesion, 26 decubitus, deep
tendon reflex, etc.).
8. Refer to findings using anatomical landmarks (e.g., left upper quadrant [of abdomen], left
lower lobe [of lung], midclavicular line, etc.).
31. 9. Use the face of the clock to describe findings that are in a circular pattern (e.g., breast,
tympanic membrane, rectum, vagina).
10. Document any change in the client’s condition during a visit or from previous visits.
11. Describe what you observed, not what you did.
32. Thorough documentation provides
I. Accurate data needed to plan the client’s care in order to ensure the continuity of care.
II. A method of communication among the health care team members responsible for the
client’s care.
III. Written evidence of what was done for the client, the client’s response, and any revisions
made in the plan of care.
IV. Compliance with professional practice standards.
V. Compliance with accreditation criteria.
VI. A resource for review, audit, reimbursement, education, and research.
VII. A written legal record to protect the client, institution, and practitioner
33. Methods used for documentation
• 1. Narrative Charting:
• a. It is the traditional method of nursing documentation.
• b. Is a story format that describes the client’s status, interventions and treatments, and the
client’s response to treatments.
• c. Easy to use in emergency situations, in which a simple, chronological order is needed..
34. 2. Source-Oriented Charting:
• Is described as a narrative recording by each member (source) of the health care team on
separate records. Because each discipline has a separate record, care is often fragmented and
communication between disciplines becomes time-consuming
35. 3. Problem-Oriented Charting:
• Documentation is on the client’s problem, with a structured, logical format to narrative charting
called SOAP:
• a. S: subjective data (what the client or family states).
• b. O: objective data (what is observed/inspected).
• c. A: assessment (conclusion reached on the basis of data formulated as client problems or
nursing diagnoses).
• d. P: plan (actions to be taken to relieve client’s problem).
• SOAPIE and SOAPIER refer to formats that add: • I: intervention (measures to achieve an
expected outcome).• E: evaluation (effectiveness of interventions). • R: revision (changes from
the original plan of care).
36. 4. PIE Charting
• :Problem, intervention, evaluation (PIE) is an acronym for problem, intervention, and evaluation
of nursing care.
• In this the careplan is incorporated into the progress notes
• In this documentation , a patients assessment is done and documented at the beginning of each
shift using preprinted flow sheet, patient problems identified in this assessment are numbered
• Documented in progress notes, worked up using PIE format and evaluated each shift.
38. 5.Focus Charting:
A method of identifying and organizing the narrative documentation of client concerns to include
data, action, and response. This method is not limited to client “problems” but allows for the
identification of all “concerns” such as a significant event (e.g., results of a diagnostic test).
Data: Subjective and/or objective information supporting the stated focus or
describing observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or protocols
and procedures initiated.
Response: Description of individual's response to medical and/or nursing care. Statement
that the Action Plan of Care outcomes have been attained or are progressing
toward attainment.
39.
40. 6.Charting by exception
• The CBE system has three key components:
• a. Flow sheets: Highlight significant findings and define assessment parameters and findings.
• b. Reference documentation: Is related to the standards of nursing practice.
• c. Bedside accessibility: Is related to the documentation forms.
41.
42. 7.Computerized documentation and
electronic health record
• 1. call up the admission assessment tool on the computer screen and key in patient data
• 2. develop the care plan using computerized care plan available for each NANDA approved
diagnosis
• 3. add the patient database as new data are identified and modify the careplan accordingly
• 4. receive a work list showing treatment, procedure, and medication necessary for each patient
through each shift
• 5. document care immediately, using the computer terminal at bedside.
43. Benefits of HER
• Providing accurate, up to date and complete information about patients at point of care
• Enabling quick access to patient record for more coordinated, efficient care.
• Securely sharing electronic information with patients and other clinicians
• Helping providers more effectively diagnose patients, reduce medical errors and provide safer
care.
• Improving patient and provider interaction and communication
• Enable safer, more reliable prescribing.
44. Contd…
• Helping promote legible, complete documentation and accurate streamlined coding and billing
• Enhancing privacy and security of patient data
• Reducing cost through decreased paperwork, improved safety, reduced duplication of testing
and improved health.
45. Recommendation on HER standards in
India
• Never give your personal password or computer signature to anyone
• Don’t leave a computer terminal unattended after you have logged in
• Know and follow the correct protocol for correcting errors
• Never create, change or delete record unless you have authority to do so
• If you inadvertently delete a permanent record report it immediately
• Don’t leave information about patient displayed on a monitor where other may see it
• Follow the facility confidentiality protocol
• Never share any information to anyone using mail or any other mode to protect it from
unauthorized access.
46. • Remember every time you log into an electronic medical record with your login credentials, you
create a trail that can be traced, and you are liable for everything you document- or fail to
document.