What information should the nurse document in the clients medical record?

What information should the nurse document in the clients medical record?

Documents of the medical history

In addition to containing the procedures in the document the general condition of the subject of care is reflected and for this it is necessary that you always have in mind what needs to be recorded, remember to evaluate the patient in the cephalocaudal direction that is to say, from head to toe. Taking into account these 3 premises:

Performed the first nursing annotation, we get to imagine the general condition of the patient, without the need to look at him. In order for me to be able to imagine all the assistance provided and how the patient was during the shift, it is necessary to make the record. But what should I write down?

I invite you to do the following exercise alone or exchange with a colleague: Make a nursing note and then, without looking at the patient, read the note and try to imagine the patient’s condition.

Nursing clinical history in word format

Law 41/2002 determines the mandatory documents that must be present in the medical record. Among them are the care planning sheets, the record of therapeutic applications and the record of constants. All of them must be present in each of the episodes with the corresponding identification of the person who performs it, since it implies legal responsibility, insofar as compliance with the law must be guaranteed.

In addition, the medical record allows access, in an organized manner, to the information necessary to provide adequate and quality health care, respecting the different models and information systems of each organization.

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The specific nursing sections are referred to in sections m and n. Thus, this law obliges the nursing professional to record, at least, the evolution and planning of care, the application of nursing therapy and the chart of constants, thus giving importance to the work carried out by nurses. These written documents, or on the most appropriate technical support, with the corresponding identification of the person who carries them out, should be included in the HC. In addition, the concept of “obligation” implies legal responsibility, so it is necessary to generate a cultural change in the work, insofar as compliance with the law must be guaranteed.

Nursing clinical history example

The clinical history originates with the first episode of illness or health check-up in which the patient is seen, either in the hospital or primary care center, or in a physician’s office. The clinical history is included within the field of clinical semiology.

In addition to the clinical data related to the patient’s current situation, it incorporates data on personal and family history, habits and everything related to the patient’s biopsychosocial health. It also includes the evolutionary process, treatment and recovery. The clinical history is not limited to being a simple narration or statement of facts, but includes in a separate section judgments, documents, procedures, information and informed consent. The patient’s informed consent, which originates from the principle of autonomy, is a document in which the patient records and signs his acknowledgement and acceptance of his health situation and/or disease and participates in the health professional’s decision making.

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Nursing clinical record format

Research Articles Quality of nursing clinical records: the generation of an assessment instrument Nursing clinical registers quality: the generation of an assessment instrument Marisol Torres Santiago-, Rosa Amarilis Zárate Grajales– y Reyna Matus Miranda— – Bachelor’s Degree in Nursing. Student of the 6th Generation of the Master’s Program in Nursing, National School of Nursing and Obstetrics, National Autonomous University of Mexico. — Master in Education Research and Development, Thesis Director, National School of Nursing and Midwifery, National Autonomous University of Mexico. — Master in Education, National School of Nursing and Midwifery, National Autonomous University of Mexico.     Correspondence: [email protected] Date received: August 3, 2010.