Patients must be asked questions that allow them to provide as much information about their health related issue. A complete medical history along with the subjective and objective data assists the nurse in reaching a nursing diagnosis (Ackley & Ladwig, 2011). There are five labels associated with nursing
Outcome 7 Contribute to Children and Young People’s Health and Safety Know the work setting’s procedures of receiving, storage and administering medicines. 1. Identify the procedures of the work setting governing the receipt, storage and administration of medicines. * Must follow the EYFS guidance (Early Years Framework For The Early Years Foundation Stage) * All medicines must be kept, stored away correctly as advised on the packet, administered also according to the instructions on the packet and out of reach of children and unqualified staff. * All medications should have the child’s name on so medication doesn’t get used incorrectly.
The key regulations we will be addressing are: Joint Commission IM. 02.02.01: The hospital effectively manages the collection of health information. ID 3: The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations. Joint Commission RC. 01.01.01: The hospital maintains complete and accurate medical records for each individual patient.
Risk Management 6. Federal Regulations As with any organization, there are federal regulations set in place to protect consumers and the organization. Health Care Organization are no exception, there are guidelines set in place to ensure that patient safety is met. Federal Regulations that the paper will discuss are as follow. 1.
Direct trust follows strict guidelines and rules related to the operation of security and trust-in system used for the health care direct exchange. Direct Trust employs its trust and security framework as a foundation for an accreditation and audit program for direct implementers/service providers, including health internet service providers (HISPs), Certification Authorities (CAs) and registration Authorities (RA). Direct Trust disperses digital certificates, aka (trust anchors) from service providers. This is done so that direct messages can be sent and/or received among providers without the need for one negotiation between depending parties, instead of having to exchange trust anchors with each other one at a time, all can obtain the trust anchors from one centralized source. (Florida HIE,
Assignment “Devise a list of guidelines for staff to follow when completing records of clients” Following the six principles of the Caldicott Report which clarifies the need to protect and respect patients /clients privacy, identity and confidentiality at all times re: their medical history/diagnoses/Care and Treatment. These are following are guidelines based on the Caldicott Report, that I would recommend for staff to follow when completing clients records. * “Justify the purpose”: Client’s identifiable information that is used within the organisation should only record what is required, it must be accurate and clearly written, up to date, relevant and regularly reviewed by a senior member of staff. * “Do not use identifiable information unless it is absolutely necessary”: When recording information write only what is necessary and be aware that the client or advocate can access their records if they wish. * “Use the minimum necessary re patient’s identifiable information”: Where the use of patient’s identifiable information is considered to be essential, only record relevant information that is required or requested.
Candidate Statement. When receiving medication it should be signed for and stored in an area that is safe and locked at all times. The person responsible should have the keys kept on them at all times and never leave them lying around where any other persons could obtain them. All controlled drugs must be locked away and recorded sufficiently. When dealing with medication the upmost care should be taken to ensure that the correct medication is given to the correct individual and remembering that each prescription is prescribed on an individual basis.
UNIT 4223-363 COLLATE AND CUMMUNICATE HEALTH INFORMATION TO INDIVIDUALS There is lots of legislation in place regarding updating and maintaining health records. The current legislation applicable to my role are: Information Governance Information governance is a mandatory to all organisations who hold health information on patients. This information covers confidentiality, data protection, information security freedom and records management. The information governance framework makes sure that all NHS organisations are clear about expected standards and all staff understands their own responsibility. My responsibility is to maintain and update patents records, ensuring that the information stays confidential and is locked away securely.
Unit 4223-338 338.1 Perform Routine Electrocardiograph (ECG) Procedures 1.2 Understand current legislation, national guidelines, policies, protocols and good practice which impact on own role 1.2 Explain own responsibilities and accountability in relation to current legislation, national guidelines, policies, protocols and good practice guidelines 1.3 Explain the duty to report any acts or omissions in care that could be detrimental. The Executive Director for Nursing and Governance has overall responsibility for ensuring guidelines are implemented. There is corporate responsibility for ensuring clinical guidelines are supported by appropriate training, policy distribution and awareness and incorporation into the clinical governance agenda, in terms of audit. All clinical staff should be aware of their own responsibility and accountability when recording or interpreting an ECG and always adhere to professional codes of practice and ensure their clinical competence is maintained. It is the responsibility of the person who is performing the ECG to ensure they provide the Doctors with a legible and accurate ECG recording.
Evidence-based Task 3 Toni Annette Roberts Western Governors University Evidence-Based Task 3 This paper will describe an appropriate perioperative process or procedure and why it needs change. This paper will explain who determined the basis for the practice in the nursing area. This paper will explain the rationale for making the decision for the procedure. This paper will explain why the procedure is performed this way. This paper will provide an APA-formatted reference list documenting more than five sources used in the review.