*Patient storyboard - age, treating team, FYIs, infections, allergies, isolations, LOS, weight.The EMR review should include (*indicates essential) It is recommended that each ward standardises the layout based on their patient population. The tabs across canīe customised to meet the specific needs of your patient group ( EMR learning resources). The Patient storyboard has a significant information which can be viewed by hovering over sections. ![]() To complete an EMR review, enter the patients’ medical record and work through the key activities in order. Review of the EMR gives an overview of the patient. The information for this assessment is gathered from bedside handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’. Please note nursing process theory referenced includes an additional phase ‘diagnosis’ which includes identification of problems, risk factors and data analysis, for the purpose of the Nursing Documentation guideline ‘diagnosis’ could occur at any phase and should be documented in real time.įig 1: Nursing Theory, the Nursing Process The Nursing Process - Nursing Theory () accessedĪt the beginning of each shift, a ‘primary assessment’ is completed as outlined in the It is continuous and nursing documentation should reflect this. Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. There is an expectation that shift required documentation is completed within 3 hours of shift start time. National Safety & Quality Health Service Standards. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the Required documentation: minimum documentation required to reflect safe patient care.Real time: nursing documentation entered in a timely manner throughout the shift. ![]()
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