Documentation Flashcards
1
Q
What would you have in your nurses kete? 5 things
A
care plans admission notes progression notes ews medication administration
2
Q
What are progress notes?
A
Medical record used by healthcare professionals
3
Q
What is in the patient progress notes?
A
All patients details and health care stautus, legal requirement
4
Q
What happens if you make an error in notes?
A
Cross out and initial
5
Q
What is focus charting?
A
Systematic approach to documentation - brings focus back to patient
6
Q
What is subjective data?
A
What the client tells you, their point of view, how they feel
7
Q
What is objective data
A
Everything you see and obs you have taken eg blood pressure
