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4:36 12:03 Suggested clip Charting for Nurses | How to Understand a Patient's Chart as a YouTubeStart of suggested client of suggested clip Charting for Nurses | How to Understand a Patient's Chart as a
Before entering anything, ensure the correct chart is being used. Ensure all documentation reflects the nursing process and the full extent of a nurse's professional capabilities. Always use complete descriptions. Chart the time medication was administered, the administration route, and the patient response.
3:50 12:03 Suggested clip Charting for Nurses | How to Understand a Patient's Chart as a YouTubeStart of suggested client of suggested clip Charting for Nurses | How to Understand a Patient's Chart as a
A medical chart is a complete record of a patient's key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
The importance of charting for nurses The information you document in the patient's medical record serves several purposes. Past surgeries, medical conditions and hospitalization are also documented. Information in the chart helps other medical workers understand what is going on with the patient.
Take Quick (HIPAA-compliant) Notes as You Go. Don't Save All you're Charting Until the End of the Shift. Chart Areas that Aren't DL Immediately. Use Automated Nurse Charting Resources. Learn the Keyboard Shortcuts for Nurse Charting Programs.
5 tips for charting in nursing. Find balance. Use technology to the fullest. Avoid double-documenting. Document in real time. Avoid precharging.
Documentation is any written or electronically generated information about a client that describes the status, care or services provided to that client. Through documentation, you communicate observations, decisions, actions and outcomes of these actions for clients, demonstrating the nursing process.
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