1.The documentation contains complete details and accurate descriptions. There are no generalisations or vague descriptions. Does...

1.The documentation contains complete details and accurate descriptions. There are no generalisations or vague descriptions. Does it meet the criteria or no? If not, why? How should it be ?

2.All client comments are documented using “client comment”. Does it meet the criteria or no? If not, why? How should it be ?

Expert Solution

Qn. No 1. It doesn't meet the criteria. It also contains:

Clearly write date and time of all nursing care notes. To avoid confusion, mention am or pm.

Sign all charting entries. Use first initial and last name. Professional status should be clearly designated. e.g. D.Rose, RN.

Qn No.2. No. The term client is a common word. The identity of the client is determined by his/ her name.

Should clearly determin the patient's name, time, circumstances. The information should be in descriptive format. Subjective data that the nurse include in the record as it is that the patient says. Verbatim written with in quotation mark.

All client related informations should be factual, accurate, complete, current and organized.

Nightingale answered 2 years ago

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