2. DOCUMENTATION
Purpose
DAR Documentation
VERBAL AND TELEPHONE ORDER
PANIC RESULTS REPORT AND HANDOVER
RECOMMENDATIONS
REFERENCES
3. At the end of the lecture, Nurses will be able to:
Familiarize and understand the Nursing policies discussed.
Strictly adhere to hospital policy and procedure.
Implement measures to maintain patient and staff safety at
all times.
4.
5. To serve as communication between
healthcare members involved in
client’s care.
To provide a permanent and legal
record to protect client, institution and
practitioner.
To ENSURE CONTINUITY OF CARE.
6. Serves as a permanent record of patient information
and care. It is a written record of a patient’s progress
and nursing care provided.
A type of documentation that is in problem-oriented
charting format, routine nursing task and assessment
data are documented in the flowsheet.
7. DATA – These are subjective or objective information
that supports the stated/main problem or describes
observation at the time of a significant event.
ACTION – Refers to past, present or future nursing
actions based on the assessment/evaluation of the
patient’s condition. This action also includes evaluation
of the present care plan and any changes and
modifications required.
RESPONSE – Describes the patient’s progress and
response to therapy. It is the discussion of outcomes
(goals) in the patient’s plan for specific problem
8.
9.
10. An order made during
emergency or life-
threatening condition
Order must be written in
the order sheet after the
disaster.
11. Order made by doctor who is physically unable to write and
order that need immediate intervention.
Will only be accepted by nurse when immediate patient care or
intervention is required.
Narcotic & high alert medication is NOT ALLOWED
MUST be signed within 24 hours
1 nurse will read back and write at the same time, must be
written in order sheet.
Limit TO communication of prescription or medication orders to
urgent situation in which immediate written or electronic
communication is not feasible.
03/07/19 at 2000H: T.O. by Dr. Ibrahim Bargash
Inj. Diclofenac Sodium 50 mg intramuscular STAT
Dr. Ibrahim Bargash/Gianne Gregorio
12.
13. A result that is outside the normal range and may
indicate high risk life threatening condition.
HOW TO DOCUMENT PANIC VALUE?
Example:
Date/Time: D – Received call from hematology department as
per brother Ali, Pt potassium level is 2.
Time: A – Informed Dr. Hatem regarding the result of patient’s
potassium level.
14. Strictly adhere to hospital and nursing Policy and
Procedures.
Proper assessment for proper intervention and
documentation.
Proper patient monitoring and management.
15. QM 002 V05
Nursing service policy and procedure NR 03 2 – V03