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CH 8 Observe/Report/Document

Horizontales
Nursing plan for care of a resident in a long-term care facility
Electronic medical record- digital patient record fora single organization or setting
Observation based on ideas perceived only by the individual involved
Noticing something
Putting into effect
Statement of a patients problems leading to nursing interventions
Standard structure for concise, factual, effective and meaning reporting of patient information.
Verticales
Observation made through the senses of the observer
Framework for nursing action
Verbal report
Actions that influence that eventual outcome of a situation
Electronic health record-patient record in digital format, not complete medical record
Law passed in 1996 protect privacy, confidentiality, medical records, and other individually identifiable patient information