Patient Chart Documentation and Vital Signs

Patient Chart Documentation and Vital
Signs
Patient Chart
Legal record for healthcare system demands, used for accreditation, medical
insurance, and legal systems.


Intervention for Low Blood Pressure
Sit down, raise feet, and hydrate to pump blood back to heart.




Intervention for High Blood Pressure
Have seated with legs down.


Good Documentation
Reflects nursing process, integral part of implementation phase.


Purpose of Patient Record
Main communication, includes Diagnosis Related Groups (DRGs) for resource
prediction.


Electronic Health Record (EHR)
Includes SBAR(R), ease of use, point-of-care, computers on wheels (COWS),
security, and personal health record (PHR).


SBAR(R)
Situation, Background, Assessment, Recommendation for record use.


Charting Error Correction