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

Thermodynamics Thermodynamics  tells us that every transformation of matter chemical  transformation is  accompanied with  energy conversion .For example  when complex  molecul

Q. What is pericardial effusion? A pericardial effusion is viewed as an echo free space surrounding the heart, most commonly seen posteriorly. Echocardiography provides

Q. Do echinoderms have circulatory and respiratory systems? In echinoderms there are not well- defined respiratory with the exception of the holothurian group and circulatory s

Describe about cardiac examination? Physical examination of the cardiovascular system is mainly discussed under four headings i.e., inspection, palpation, percussion and auscul

Proteins of Animal Origin - Fish Fish: The edible portion is skeletal muscles of the body. Even though the skeletal muscles of different animals are basically similar, fish spe

DISORDER S OF MALE REPRODUCTIVE SYSTEM (i) Prostatomegaly - Enlargment of prostate gland. It causes difficult & painful micturition. (ii) Impotence - Inability of male

Oxidation of malate to oxaloacetate Oxidation of malate to oxaloacetate: Malate  is oxidized to oxaloacetate  by malate dehydrogenase and NAD'  is  required as coenzyme.  Thi

State the concept of type locus interaction Some of the major contributions included the concept of type locus interaction, the analysis of quantitative as opposed to qualitati

Alkaline Phosphatases use water as a second substrate. Why do we still treat their kinetics as if they were for a single-substrate reaction?