objectives at the end of this lecture the students will be able to define terms listen principles of recording reporting understand different methods of documentation discussing nine purposes for writing ...
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...Objectives at the end of this lecture students will be able to define terms listen principles recording reporting understand different methods documentation discussing nine purposes for writing a record discuss improper technique report out line definition introduction health care today is multidisciplinary endeavor even within walls single institution patient receives services from many departments more than one service unit communication between institutions promotes continuity an essential element quality in client community agencies rely on clients records nurse has planned given evaluated s status response written legal all interventions with assessment diagnosis plan implementation evaluation increasingly sophisticated management information stems are being designed manage specific data following elements good clarity conveying legibility timeliness suitability purpose simplicity confidentiality truthfulness organization conciseness...