As an educator of nursing students, the writer is concerned not only with the present gaps in nursing documentation to the electronic record, but with abilities of nursing students to learn the skill. There are a variety of entities within the nursing industry that can use PowerPoint presentations for different kinds of activities and environments. RECORDS & REPORTS: DOCUMENTATION . A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Nursing admissions 2018 | Nursing admissions 2018 starts in DPU - "Dr. D Y Patil Vidyapeeth (DPU), Pune offers BSc Nursing course. documentation, recording, and reporting. Well-organized layouts and exceptional designs will certainly leave a nice impression on every single visitor. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. Course Hero, Inc. Please remember to read the disclaimer. View NURS 1101 Nursing Documentation and Reporting.ppt from NURS 1101 at Texas A&M University. Canadian Clinical Nursing Skills and Techniques helps equip you with the skills you need to successfully care for patients within the Canadian social and institutional context. Documentation is the primary way that we, as RN’s, demonstrate what we did, for whom, when, and with what effects. psychiatric nursing documentation examples Speaking of templates, you can easily find numerous templates related to the practice of health care, such as the Health History Questionnaire and the Patient Satisfaction Survey. Documentation and Reporting - SlideShare A nursing PowerPoint can be used by nurses or for the processes and lectures that benefit nurses. The nursing process requires assessment, diagnosis (nursing), planning, implementation, and evaluation. FINAL PROJECT REPORT August 2007 Project no. B.Sc. Values and uses of records. Nursing documentation can be accepted in both verbal and written form. In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional. NURS 1101 Nursing Documentation and Reporting.ppt, Copyright © 2021. Conclusion. • Describe the elements required to document AEs. A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Elements of Effective Documentation Complete:- • The information within a recorded entry or a record must be complete, containing appropriate and essential information. Nurses must allocate time for both hands-on care and documentation, as it is the two together that constitute total patient care. C. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse.   Privacy Documentation is the primary way that we, as RN’s, demonstrate what we did, for whom, when, and with what effects. • Documentation is anything written or printed on which you rely as record or proof of patient actions and activities. More than 100 years later nurses began to develop their own documentation systems based on nursing diagnoses. Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential … Now customize the name of a clipboard to store your clips. Nursing Documentation: Charting, Recording, and Reporting: 9780397550104: Medicine & Health Science Books @ Amazon.com Purposes of records. 45. The expert will look at the nursing documentation for clues and evidence that the care rendered wasn't consistent with appropriate nursing care in order to form an expert opinion. As an RN, you must: 25) Demonstrate skill in written and/or electronic communication that promotes quality documentation and communication between team members. History. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing … Documentation also ensures a matter of professionalisation and proof … Nursing documentation is essential for good clinical communication. 3. The carer is standing behind the elderly man and is giving him a massage and is leaning forward slightly over the elderly man in an affectionate manner.