Unit 2 - DB - Record Components & Documentation Requirements- Medical Records

Unit 2 - DB - Record Components Documentation Requirements- Medical Records

What are three or four requirements for documenting the following A patient 's pain assessment and treatment - JCAHO in the year 2000 has developed criteria in the manner in which pain should be assessed and documented . The Nurses need to be competent in evaluating and documenting pain . The patient has to also be reassessed for pain on a routine basis . If pain is affecting normal functioning at any stage effective measures need to be taken to ensure rehabilitation and relief The nurse would

have to assess pain at various events including admission of the patient , reporting of pain to other healthcare professionals , after procedures or surgeries , or during discharge planning . Various criteria of pain including location , duration intensity , frequency , character and comfort levels need to be recorded A Numeric Pain Rating Scale should be used in the EMR to determine the level of pain from 0 to 10 . In patients who are not communicating , the FLACC pain scale should be used . Preferable Pain assessment should be done in the nursing flow sheet (which would help review the pain characteristics at various period of time (University of Virginia 2008 Medication administration - the Drug being administered should be named appropriately so that any previous drug allergy reaction that the patient experienced can be identified before actually prescribing the drug . The physician prescribing the drug can import the drugs from the online catalog . There are several tools which work on the back-end of the...