Question

As a nurse what is the process and documentation required for admission for patient?

Answer 1

Process of admission includes firstly the client must be informed ,in understandable terms regarding the admission procedure then the nurse take informed consent which indicates the client's participation in the decision regarding health care.

Documentation findings serves as a source of client information for other health care providers.Record findings about the client 's history and physical examination as soon as possible after completion of the health assessment.

The nurse should follows while documentation:

1.Date and time entries

2.Provide objective,factual and comolete documentation

3.Document care ,medications,treatments and procedure as soon as possible after completion.

4.Document client response to interventions.

5.Document consent for or refusal treatment.

6.Sign and title entry.

7.Maintain privacy and confidentiality for documented information.

8.Donot use unacceptable abbreviations.