documentation

documentation is a vital skill nurses need to be able to do accurately for many reasons. i will list a few:

-you are not with the patient 24/7 and anyone coming in can get information about the patient by readings their form of documents -can illustrate abnormalities. for example, recording pulse and blood pressure over a period of time and seeing a spike can cause a need for concern that needs to eb addressed -can be used for legal purposes (factual) -shows what medication the patient has and has not had -has the patients name, so you can address them -states their duration in care, why they are there and what resources are being used to address their conditions

-mel

Privacy and Confidentiality Healthcare providers need to keep every patient information a secret- between the healthcare providers and the patient and their family only. This is needed so that the patient and family can trust you. The patient has a legal right to expect that the information shared by him/her will not be open to the public.

- accurate - complete - concise - objective/factual - organised - timely - legible - maintain confidentiality - non-erasable - accurate date and time - signature, name and designation of documenter - on correct form - using professional language - black ink
 * Principles of Documentation **