Utilizing critical reasoning and the nursing process, the student is expected to:
1. Identify the parts of a medical record: physician's history and physical, physician's orders, physician's progress notes, vital sign record, nurse's shift assessment, nursing progress notes, other health care team members’ progress notes, lab reports, radiology reports, operative report, and others
2. Distinguish between initial assessment, ongoing assessment, and focused assessment
3. Describe nursing progress notes, nursing care plan, interdisciplinary plan, kardex
4. Document patient assessment, nursing progress notes, Vital signs, problem updates, discharge teaching, medications, and activities of daily living (ADL)
5. Identify the necessary information to document. (per BNE Standards of Practice)
6. Accurately and completely report and document:
a. the patient’s status including signs and symptoms;
b. nursing care rendered;
c. physician, dentist or podiatrist orders;
d. administration of medications and treatments;
e. patient response(s); and
f. contacts with other health care team members concerning significant events regarding patient’s status;
7. Discuss guidelines for documentation that is pertinent, concise, accurate, and legal advisable
8. Discuss the patient's right to access their medical record and expectations of confidentiality (HIPAA)
1. Review module objectives.
2. Learning Resources:
Review:
RNSG 1105 & 1413 materials as necessary
Facility Policy & Procedure Manual
Charting guidelines for the patient care unit