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Flashcards in Preparation for the Nursing Laboratory Deck (14)
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What is integrated report writing?

A single patient record containing chronological entries made by all health care professionals involved in the person's care


Define date and time in terms of documenting

- Document data and time for legal reasons and for patient safety
- Record in 24 hour time or using AM and PM
- Double check electronic charts for a time stamp


Define timing in terms of documenting

- Follow policy regarding frequency of documenting and increase if needed due to seriousness of condition
- No documenting should come before care but should be priority after assessment


Define legibility in terms of documenting

- Must be legible to prevent misinterpretation
- Usually hand printing is recommended


Define permanence in terms of documenting

- All entries must be made in black ink


Define accepted terminology in terms of documenting

- Use only accepted abbreviations, symbols and terms
- Terminology may be generalised to the industry or specialised to the organisation


Define correct spelling in terms of documenting

- Spelling is essential for accuracy in documentation


Define signature in terms of documenting

- Each recording must be officially signed by a health practitioner


Define accuracy in terms of documenting

- Person's name and information should be attached and correct
- When a mistake is made, draw a singular line through the mistake


Define sequence in terms of documenting

- Document in order of events occurring


Define appropriateness in terms of documenting

- Record only information pertaining to the patient's healthcare
- Appropriate language is required


Define completeness in terms of documenting

- Information recorded must be completed and reflect the nursing process
- Recordings written in sentences


Define conciseness in terms of documenting

- Recordings need to be brief and to the point
- The patient's name and 'patient' is omitted


Define legal prudence in terms of documenting

- Provides information about care delivered to a person that can act as legal document as evidence in court