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Common examples of documentation in clinical nursing include patient assessments, vital signs, weight, height, medication administration, intravenous and blood product therapy, nurses notes, physician/provider orders and notes, laboratory values, radiology reports, surgery reports, and therapy notes.
What is home care documentation?
Documenting at the patients home will enable clinicians to record medication, treatment, and care plan changes during the visit/shift. These changes will immediately be available for the next visit for the next clinician to administer the right medication and treatment.
What do home care records typically include?
Unlike traditional healthcare settings where a team of medical professionals attends to a patient, home health often involves a single provider interacting with the patient. This makes thorough documentation even more critical, as errors may easily go unnoticed without a second team member reviewing the records.
What is the meaning of care documentation?
For the clinician and the patient or client, it is a record of diagnosis and treatment that serves continuity of care both by the treating clinician and any succeeding caregiver.
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This transmittal introduces Chapter 40, Hospital and Hospital Health Care Complex Cost Report,. Form CMS-2552-10, which contains instructions for the completion
by WSCANP CHC Documentation should include the following: Reason for continuous care. Vital signs (as appropriate). Observations of the patients condition.
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