Professional Documents
Culture Documents
- Plan each day prior to the start of the shift (between 0700- - Documentation will be - By the ending of
0730) completed as events NURS208
- Provide realistic timing on my chart, including time for the occur
unexpected - Including relevant
- Start charting at the beginning of the day, and while events information in the
occur charting
- Make sure to document in a timely manner so - Using appropriate
interdisci0plinary team can review for patient timing for each event
so interdisciplinary
team can review
LEARNING PLAN
- Do a head to toe assessment first thing in the morning - Begin the day doing a - By the ending of
along with vital signs head to toe assessment NURS208
- Be aware of the previous days documentation on head to - Be prepared with the
toe assessment for the patient knowledge of the
- Be aware of any changes away from baseline assessments previous day to assess
- Make sure everything on a head to toe assessment is for changes
covered - Document accordingly
- Document the assessment in a timely manner so the
interdisciplinary team can review