General guidelines of maintaining records of patients, Biology

General Guidelines

While working in the ward, you are always required to record. You should follow the general guidelines while recording which are as follows:

  1. All entries on the chart must be accurate and factual. 
  2. Exactness is essential in changing times, effects and result of treatments and procedures. 
  3. Full dates including year should be written. 
  4. Use ink while entering and write legibly. 
  5. Each entry must follow by your first initial, last name and title. 
  6. Ditto mark and erasers are not acceptable. Errors are corrected by drawing a single line though the incorrect material and writing in the correct entry as close to the mistaken entry as possible.
  7. Lines should not be left completely or partially blank in the record. If a line is skipped or not filled completely, draw a single line through the remainder to prevent charting by someone else. 
  8. Descriptions are essential when charting about drainage, stool, vomitus, pain and any other diagnostically valuable occurrence. 
  9. The time should be recorded on all entries. 
  10. Only abbreviations accepted by the hospital are allowed on the record. 
  11. Each page of the chart must be identified with the name of the patient/client, hospital identification number and any other data required by the hospital. 
  12. The reliance on various facilities as a means to reimbursement for health care facilities had placed increased emphasis on the need for accurate documentation. 
  13. The chart should reflect nursing assessment and nursing therapy prescribed by the professional registered nurse and reflected on the nursing care plan.
Posted Date: 10/27/2012 7:33:09 AM | Location : United States







Related Discussions:- General guidelines of maintaining records of patients, Assignment Help, Ask Question on General guidelines of maintaining records of patients, Get Answer, Expert's Help, General guidelines of maintaining records of patients Discussions

Write discussion on General guidelines of maintaining records of patients
Your posts are moderated
Related Questions
The gaseous pollutants can be controlled through the techniques of combustion, absorption adsorption and cold trapping. (a)   Combustion: Though combustion is a major cause of i

Observing where soil bacteria live Dig up a clover, alfalfa or soy-bean plant. Carefully increase all the soil from the roots and see if you can find the little white nodules o

Determine the groups of soil organisms The soil organisms are classified into two broad groups viz. soil flora (related to plants) and soil fauna (related to animals) which ar

Explain Adverse effects of ritonavir - Adverse reactions are common to full doses of ritonavir, but less common with the low doses used in PI combinations. Ritonavir can cause

Q. What are the three stages into which the cell respiration is divided? The three stages of aerobic cell respiration are glycolysis, Krebs cycle and respiratory chain also kno

Write in 5-6 lines about food pyramid. The diabetes food pyramid divides food into six groups. These groups vary with each other on the basis of si-e occupied in the pyramid.

Question 1 List various liver function tests. Discuss the importance of each test. Add a note on standardization of various liver function tests Question 2 Discuss the follow

How Rb protein's phosphorylation state affects the cell cycle and cancer progression. please put link or citation of where you find information.

What is an etiological agent of disease? An etiological agent of disease is the agent that causes the disease. It might be a living being, substance or environmental fact.

Why do you think that bioinformatics is important?         Ans) Today, we can use computers to access much more biological data than still before. You can learn a lot by analysi