- *enter info in a complete, accurate, concise, current and factual manner.
- *Make sure your documentation reflects the nursing process and your professional responsibilites.
- *Record patient findings rather than your interpreations
- *Avoid using generalizations
- *Note problems in a orderly, sequential manner.
- * Avoid words such as "good", "average" , "normal" or "sufficent"
- * Document in alegally prudent manner.
- *Chart in a timely manner . Follow agency policy regarding frequency of documentation.
- *Indicate each entry the date and both the time the entry was written and the time of pertient observations and interventions.
- *Document nursing interventions as closley as possible to the time of their execution. Never leave for a break from a seriously patient until all significant data is recorded.
- *Never document interventions before carrying them out .
- *write a progressive note for each of these instances
- upon admission , transfer and discharge
- when a procedure is preformed
- upon recieving a patient postop or post precedure
- upon communicating with pysician regarding critical situation
- for any change in patient status
- Check to make sure you have correct chart before writing .
- Chart on proper form as designated by agency policy.
- print or write legibly in dark ink to ensure permanance.
- Date and time each entry
- Chart nursing interventions chronologically on consecutive lines. never leave spaces, draw a single line through blank spaces
- *Sign your first intial and last name and title to each entry. Do not sign notes describing interventions not preformed by you that you have no way of verifying.
- *Do not use dittois or erasures or correcting fluids. A single line should be drawn through an incorrect entry and words. "mistaken entry or "error in charting" should be printed above or besides the entry and signed. The entry should then be rewritten.
*Patients have a right to know that information in their medical records will be kept private.
Dependant nursing interventions/actions
Physician-initiated interventions, or dependant nursing nursing actions, invole carrying out physican -prescribed orders, State Nurse Practice Acts specify from whom nurses can recieve orders. Nurses are still accountable for dependant orders they implement and are thus responsible for the clarification of any questionable order.
Independant nursing interventions/actions
nurse initiated interventions, or independant nursing actions, involve carrying out nurse -prescribed interventions resulting from their assesment of patient needs written on the nursing plan of care, as well as any other actions that nurse iniatied without the direction or supervision of another healthcare professional. Nurses are accountable for their assessments and their nursing responses.
Adverse effects of a drug
*undesirable effects other than the intended therapuetic effect of a drug .
is an immune system response that occurs when the body interprets the administered drug as a foriegn substance and forms antibodies against the drug.
occurs when the body becomes accustomed to the effects of a particular drug over a period of time. Larger doses of the drug must be taken to produce the desired effect.
are specific groups of symptoms related to drug therapy that carry risk for permanent damage or death. And occur from a cummaltive effect.
sometimes called paradoxial effect. is any unusal or peculiar response to a drug that may manifest itself by over response, under response, or even the opposite of the expected response. Idiosyncratic effects are related to a patients unique rsponse to a drug and are thought to be related to gentic enzyme deficiences that lead to an abnormal mechanism of drug breakdown. Older patients often have unpredictable and erractic responses to meds.