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1. Written nursing care plan or interdisciplinary care plan is framework for documentation 2. Charting organized by nursing diagnosis or problem 3. Implementation of each intervention documented on flow sheet or in nursing notes 4. Evaluation statements placed in nurse's notes indicate progress toward the stated expected outcomes and goals
Study with Quizlet and memorize flashcards containing terms like nursing process, purpose of documentation, Face Sheet and more.
Graphic sheet. Record of serial measurements and observations, such as temperature, pulse, respiration, blood pressure, weight. Nursing care plan. Care plan for the patient, including nursing diagnoses, goals and expected outcomes, and nursing interventions. Nurse's notes.
Study with Quizlet and memorize flashcards containing terms like What are the purposes of documentation?, Definition of Documentation, Medical Record and more.
7 Documentation of Nursing Care CHAPTER PRETEST. Have the students answer these questions prior to covering this chapter to understand where they stand in relation to the content. The written document that contains the patient’s information is known as the: a) consent. b) medical record. c) protocol. d) report sheet.
Video answers for all textbook questions of chapter 7, Documentation of Nursing Care, Study Guide for Dewit’s Fundamental Concepts and Skills for Nursing by Numerade
Sample Documentation of Unexpected Findings. Attempted to initiate IV infusion in right hand with existing 22-gauge IV catheter. IV site free from pain, redness, or signs of infiltration. IV site flushed readily with normal saline.
