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The Hospice Nurse must document on every note the following items: The terminal diagnosis. Pain and pain medications used/available. Appetite. Current abilities to perform ADL’s and …
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Wound Documentation [+ Free Cheat Sheet] | Lecturio
Oct 9, 2024 · This guide provides tips for wound assessment and documentation, including wound measurements, types of wounds, signs of abnormal wound healing, and assessment of the …
What Are the Best Practices for Nursing Documentation ...
May 7, 2024 · Nursing documentation is an essential aspect of patient care and plays a pivotal role in enhancing communication between healthcare professionals, recording medical history …
Nurse Charting 101: Your Guide to Documentation | Berxi
Jul 24, 2024 · Patient documentation is permanent record, and, well, you probably became a nurse for the hands-on interaction. That’s OK! Here’s a refresher on what and how to chart as …
Best Practices for Documentation: A Nurse’s Guide
Sep 4, 2024 · Documentation is an essential part of your role as a nurse. You need to have good documentation skills to ensure patients get the appropriate care. An error could lead to …