The intention of the document is to assist the registered nurse to meet their standards of practice related to documentation. [...] The rights of clients and obligations of public agencies are outlined in Freedom of Information and Protection of Privacy Act (FOIPOP) and the Personal Health Information Act and often are summarized in agency policies. [...] When nurses collaborate with members of the interdisciplinary team and develop and/or modify the plan of care based on the collaboration, they should document the following: • date and time of the contact • name(s) of the people involved in the collaboration • information provided to or by healthcare providers • responses from healthcare providers • orders/interventions resulting from the collabor [...] For example, if a nurse seeks clarification from a physiotherapist related to mobilization of a patient the nurse should record the reason for seeking clarification, the name of the healthcare provider providing the clarification, the action s/he took as the RN, and the expected outcome. [...] From entering requests for tests and consultations to reporting of diagnostics Telenursing testing, to the documentation of care provided, electronic Another document published documentation is part of the everyday care of clients.
- Pages
- 31
- Published in
- Canada
