Assessment Flow Sheet Nursing Education Requirements
Vi. If there is skin and/or wound concerns, document in the client Progress/Nursing Notes and the paper Wound Assessment & Treatment Flow Sheet or electronic wound assessment vii. Ensure the date, month, year, and initials are complete. 1/8″ Margin all around. The Printer will trim too the margin area. BARBARA ACELLO, MS, RN CLINICAL TOOLS AND FORMS FOR LONG-TERM CARE 29417_CTFLTC_spiral_Cover.indd 1 6/15/15 2:07 PM Course Planning Tip Sheet Gap Analysis. A. Gap Analysis. is similar to a. Needs Assessment, but it allows for a more standardized process of determining what the gap-in-knowledge (or need) is. It is important to perform a Gap Analysis to justify the necessity for the educational activity and to guide you to select the appropriate teaching and Restraint flow sheet 13. Discharge nursing assessment 14. Patient discharge instructions 15. PCA administration record 16. Peritoneal dialysis flow sheet 17. Finger-stick accession quality control form 18.
Pressure ulcer risk assessment/flow sheet 19. Patient classification system, if applies In 1990, the Oncology Nursing Society (ONS) Radiation Therapy Special Interest Group (RT SIG) established a work group in an effort to improve and standardize the documentation of nursing care provid-ed to patients receiving radiation therapy. Improved documentation of side effect management and patient education also was a goal of this task. Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse. Documentation for this resident. Nursing sees the wound during dressing changes. Nursing should be assessing the circulatory status. Nursing and therapy need to. communicate. about what is happening with this resident.
One more question Since the resident is skilled for therapy, only the therapy documentation counts, right? Per flow sheet, voided clear amber urine at 0715. C/O abdominal pain of 7 on 0‐10 pain scale. Abdomen firm, distended, and tender to slight touch. Bowel sounds hyperactive in RUQ and absent in remaining quadrants. States she does not know when she last had a bowel movement.
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