What does documentation include?

What does documentation include?

The aim of the documentation is to make it possible to find information (documents) that is stored permanently in writing or in some other way. Documents in this sense can be specialist books, magazine articles or other publications, but also archives, images, films, sound recordings and the like.

What is a documentation requirement?

The obligation to document includes the doctor’s obligation to compile all pieces of evidence that he or one of his assistants has produced himself or received from a third party as part of the treatment of a patient.

What can you write in the nursing report?

These 5 rules will help you when writing a care report in the elderly care rule: Formulate the care report accurately and precisely, without evaluating. Rule: Not only enter the special features in the care report, but also your reactions to them. Rule: Pay attention to a continuous care report.More entries…•

What do you have to consider with documentation?

3 requirementsTimely documentation.Document-proof pen (ballpoint pen)Statement of date and time.Writing-free and as objective as possible wording.Legible strikethrough in the event of an incorrect entry (the strikethrough must still be legible)

What must be in a care documentation?

These areas are: • Master data, • Nursing anamnesis/collection of information including recording of nursing-relevant biographical data, • Nursing planning, • Nursing report, • Proof of performance. Depending on existing care problems, the documentation system may need to be expanded as part of the agreed services.

What is the function of the nursing documentation?

The nursing documentation serves to ensure the next work steps of the nursing staff and the cooperation in the care of the care recipients (patients, clients, residents) in the nursing team and with involved professional groups such as doctors.

Why is nursing documentation so important?

The documentation of all care measures is the most important part of care planning. This data enables professional caregivers to accurately assess the outcomes of care. Due to the complete documentation, every member of the care team can understand all actions. …

Why is nursing documentation necessary?

Above all, it is important that the documentation remains useful. So that important medical information is recorded in a central location. In this way, everyone involved in the care knows, for example, what medication has been taken. So that changes are noticed and can be correctly assessed.

Why is documentation so important?

The essence of documentation consists in preparing, structuring and preserving information of any kind for future use. Documentation also plays an important role in private, profit-oriented companies. …

What are the goals of documentation?

The aim of medical documentation is to organize information and knowledge about clinical pictures and treatment methods (types) and for the individual cases of individual patients (instances) in such a way that medical care can be supported in the broadest sense.

What are care goals?

The nursing goals can refer to physical performance and abilities, physiological parameters, knowledge, behavior and personality traits, findings, emotional experience and subjective feeling as well as the recognition of physical changes.

What does care mean?

1 Definition In medicine, a resource is an aid, financial means, personnel or skills that are available to and can be used by a healthcare professional or a patient.

What are resources simply explained?

Resources are the means needed to perform a specific action. Resources in the narrower sense are the raw materials and energy sources available on earth. A distinction is made between reserves and resources.