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The process of obtaining organizing and conveying people health information to others in print or electronic

For quality assurance for facilitation between healthcare professionals to communicate patient plan of care to demonstrate accountability to meet legal requirements

communication education research assessment planning auditing legal requirement

All healthcare provider Those with firsthand knowledge

clear, concise,accurate,truthful,patient centered relevant data all ongoing monitoring and communication care nd service provided evaluation of outcome do not document personal judgement

at the time of event or asoon as possible not later end of shift as per agency policy never document before you do something

MAR- Medication administration record CSRS- Clinical safety reporting system

Documentation is not optional It is a legal document if not documented it never happened

Confidentiality

Ability to share client health information with implied consent only for the purpose of priding care

Narrative- storylike problem oriented medical report-database, problem list,care plan , progress note

S_subjective data O- objective data A- assessment P- plan of care I- Intervention E-evaluation

P-Problem I- Intervention E-evaluation

F-Focus Specific client concerns ( not a diagnosis) D- data both objective and subjective A-Action R-patient response to the care or action

Chronological order Coherence and cohesive

Verbal or non verbal

SBAR is commonly used can be orally, audio recording,written info or at patient bedside

Essential background info relevant assessment or change chief nursing diagnosis relevant family info Discharge plan priority needs

Writing all the routine care writing all the info of the patient which is already on their chat writing critical comments about patient-patient is too sturbborn describe basic steps of an action Describe result vaguely Leaving incoming nurse to guess what to do next

Telephone order via the phone

Voice order physically

Clearly indicate if the chatting is late only document what you see or do name date time and signature

Reduced hospital cost nurse job satisfaction compliance with acrreditation standards Dev of common clinical database

Requires strong security measures for privacy Information can be unavailable during breakdown, power outage are expensive and needs to be updated frequently extended training for staff

Standardized verbal communication tool,during emergencies Situation- identify yourself, the patient and what is going on Background-Brief history of the client, allergies,diagnosis,vital signs assessment-what you think is wrong-level of consciousness,patient pain level Recommendation/request-your suggestion, propose an action , then wait for physician to tell you what to do