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Charting to the negative is discouraged in nursing except in the field of Hospice. Most charting should show improvement of symptoms and positive outcomes of interventions. With negative charting the nurse focuses on the decline of the patient. Example would be, lungs diminished, HOH, history of constipation, SOB, shuffling gait, poor appetite, weakness, no urine output, edema.
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The English Patient.
Some of the tests that are required in order to give a patient the diagnosis of being bipolar include a physical exam, lab tests, psychological evaluation, and mood charting.
It basically means that if you come, please remain patient and have your ears attend as in listening
"up ad lib" is a term used in charting or in patient care plans. It means "up as desired" and that the patient may be up (out of bed) whenever he/she desires to be out of bed. There are no restrictions on getting out of bed.
Direct Care:'Direct care' is care that is directly to the patient, this may even be on a one-to-one basis, where care is provided directly to the patient. E.g. Nurse, Doctor, etc.Indirect Care:'Indirect care' is care but not directly like a doctor or a care worker, but a cleaner or a receptionist who plays a part in the patient's healthcare or the service the patient uses but not directly them or with them this will ultimately benefit them.
A patient waiter is no loser
Electronic medical record (EMR) systems assists health care professionals to store and share patient information across disciplines and across facilities. The EMR system "provides timely and efficient access to medical records without compromising patient privacy, and allow[s] patients to engage in their own health care" (Jerome, DeLeon, James, Folen, Earles, & Gedney, 2000, p. 409). The EMR is a computerized patient charting system. Computerized charting allows for entry of interdisciplinary data and examination of specific patient information. Computerized charting of assessment data, diagnostics, interdisciplinary treatment plans, and evaluation of treatments enhances continuity of care across shifts and across disciplines. Computerized charting requires that a minimum standard is documented, preventing the omission of essential patient information.Reference:Jerome, L., DeLeon, P., James, L., Folen, R., Earles, J., & Gedney, J. (2000). The coming of age of telecommunications in psychological research and practice. American Psychologist, 55(4), 407-421. Retrieved from CINAHL Plus with Full Text database.
Planning is charting the future course of action at present?