ppt课件-documentationguidelines-greaterbaltimoremedicalcenter.pptVIP

Documentation Guidelines Greater Baltimore Medical Center General Documentation Information Most nursing documentation is completed on the computer using Meditech PCS Agency nurses will be required to take an 8 hour Meditech course taught by GBMC before beginning to work at the hospital This class will cover order entry, documentation, and barcoding medication delivery / using the electronic medication administration record Patient Care System (PCS) PCS is the system for documentation that reflects the nursing process, encourages clear and concise charting, is legally sound, and focuses on patient interventions to support patient outcomes All information entered through PCS can be viewed in the EMR (Enterprise Medical Record) With PCS, you are able to: Fill out the Admission Database Record vital signs and IOs Document the patient’s Past Medical History Document your head-to-toe assessment (using System Flowsheets) Enter nursing notes Add Care Plans and record outcomes View and print Kardexes and patient reports Enter lab, radiology, respiratory, diet, and nursing orders through order entry Document medication administration through the electronic MAR Shift A shift is defined as 12 hours Documentation that is required q shift is to be documented once every 12 hours, unless physician orders or unit specific policies dictate otherwise Change in patient status or change of care provider necessitates a repeat of the q shift documentation (i.e. Patient System Flowsheets) Real Time Documentation Documentation completed at the time the intervention is performed In the event that “real-time” documentation is not possible, documentation that occurs within one hour of the intervention is acceptable, except for those interventions with a time interval less than one hour (i.e. q15min) Any documentation entered into Meditech after the one hour time interval must be retrospectively documented by defining the exact time the