miércoles, 8 de agosto de 2012

Nursing homes: categories of care and documentation.


CATEGORIES OF CARE

e.g: NH (nursing home) RC (residencial care).
-NH-1
-NH-PH
-RC-1
-RC-MP ( E )
-RC-PH ( E )



CHARTING AND DOCUMENTATION (nursing handover)


-Patient record:
-Care plan.
-Observation chart.

CARE PLAN (usual documents used).

  • ADMISSION FORM.



  • GETTING TO KNOW YOU FORM.
  • SUMMARY OF DAILY LIVING ASSESSMENT (to identify care plans needs).



  • MONTHLY WEIGHT, BLOOD PRESSURE, PULSE CHART.
  • CLINICAL RISKS:


  • DOCTOR ADVICE/VISITS.
  • BLOOD  RESULTS.
  • SPECIMEN  RESULTS.
  • DENTIST / PODIATRY.
  • OPTICIANS /PHYSIOTHERAPY/ DIETITIAN.
  • ACCIDENTS/ INCIDENTS.
  • HOSPITAL  ADMISSIONS.
  • NAMED  WORKER REVIEWS / NAMED NURSE ( named nurse: nurse designated as being responsible for a patient's nursing care during a hospital stay and who is identified by name as such to the patient. The concept of the named nurse stresses the importance of continuity of care).
  • RELATIVES: COMPLAINTS, COMPLIMENTS.


ABBREVIATIONS

BP: blood pressure (Reading: 120/80 - one hundred and twenty over/ on eighty).
P: pulse (Reading: 120 - one twenty).
c/o: complain of.
ADLs: activities of daily living.
Pt: patient.
obs: observations.

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