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|Title:||Documenting and reporting||Contributor(s):||Parmenter, Glenda (author)||Publication Date:||2010||Handle Link:||https://hdl.handle.net/1959.11/4915||Abstract:||After completing this chapter, you will be able to: • List the measures used to maintain the confidentiality of patient records. • Discuss reasons for keeping patient records. • Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerised records, and the case management model. • Explain how various forms in the patient record (e.g. flow sheets, progress notes, care plans, critical pathways, discharge/transfer forms) are used to document steps of the nursing process (assessment, diagnosis, planning, implementation and evaluation). • Compare and contrast the documentation needed for patients in acute care, home health care and long-term care settings. • Identify and discuss guidelines for effective recording that meets legal and ethical standards. • Identify essential guidelines for reporting patient data. • Explain the reason for limiting the use of abbreviations in clinical documentation.||Publication Type:||Book Chapter||Source of Publication:||Kozier and Erb's Fundamentals of Nursing: First Australian Edition, v.1, p. 254-276||Publisher:||Pearson Australia||Place of Publication:||Sydney, Australia||ISBN:||9781442504691
|Field of Research (FOR):||111003 Clinical Nursing: Secondary (Acute Care)||HERDC Category Description:||B2 Chapter in a Book - Other||Other Links:||http://trove.nla.gov.au/work/4019874?selectedversion=NBD44600988
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|Appears in Collections:||Book Chapter|
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