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
Q. What is xaxim? Most pteridophytes have subterraneous stems similar to the substrate called as rhizomes. Xaxim is a kind of pteridophyte with an aerial stem in generally perp

advantages of cuticle of anthropodes

Circulatory System - Developmental Changes We have learnt that throughout foetal life, gas exchange takes place, only through the placenta and not through lungs. Therefore, t

What is ascaris? What is the disease caused by this worm? Ascaris, or Ascaris lumbricoides, is an animal of the nematode phylum, i.e., a roundworm. Ascaris causes ascariasis, a

Bile salts or bile acids are polar derivatives of constitute and cholesterol the major pathway for the excretion of cholesterol in mammals.  In the liver, the cholesterol is circul

Explain about the supply curve or supply schedule. The supply curve or schedule shows the total quantity of a good or a service supplied within aggregate, by whole sellers or f

Two important human fossils that throw much light on the human ancestory were discovered in .Olduvai beds in Africa and in central Java respectively. Although the development of bi

Hard paste removal -    Hard setting Ca(Ho) 2 paste (like Endocal 10) can be softened by EDTA and removed by file or microdebrider. -    Care must be taken not to gouge or

What is hemodialysis? Hemodialysis is the artificial blood filtration made by exact machines in substitution of the kidneys. Hemodialysis may be essential in patients suffering

Q. Carbohydrates requirement during myocardial infarction? The protein intake generally remains the same as per the RDI i.e. 1.0 gm protein per kg body weight per day. Adequate