You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 12-year-old boy who underwent an emergency appendectomy. According to the report, his appendix ruptured and significant actions were performed to decrease the chances of his developing peritonitis. Upon arrival to your unit, you perform your initial assessment, including the wound site. After completing your assessment and performing the immediate postoperative orders the health care provider wrote, you return to offering nursing care to the rest of the patients on your team. (Learning Objectives 2 and 8) a. Which topics would you expect to include in your documentation from this case? b. When would you expect to record your documentation? c. How often would you collect data (perform assessments) from the patient? d. Where would you expect to find pertinent information regarding the patient’s surgery and interventions performed during surgery? e. Regarding confidentiality, what information can be shared with classmates? Describe the criteria and purpose for sharing patient information with others.
You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 12-year-old boy who underwent an emergency appendectomy. According to the report, his appendix ruptured and significant actions were performed to decrease the chances of his developing peritonitis. Upon arrival to your unit, you perform your initial assessment, including the wound site. After completing your assessment and performing the immediate postoperative orders the health care provider wrote, you return to offering nursing care to the rest of the patients on your team. (Learning Objectives 2 and 8) a. Which topics would you expect to include in your documentation from this case? b. When would you expect to record your documentation? c. How often would you collect data (perform assessments) from the patient? d. Where would you expect to find pertinent information regarding the patient’s surgery and interventions performed during surgery? e. Regarding confidentiality, what information can be shared with classmates? Describe the criteria and purpose for sharing patient information with others.
Essentials Health Info Management Principles/Practices
4th Edition
ISBN:9780357191651
Author:Bowie
Publisher:Bowie
Chapter7: Numbering & Filing Systems And Record Storage & Circulation
Section7.1: Numbering Systems
Problem 5E
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You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 12-year-old boy who underwent an emergency appendectomy. According to the report, his appendix ruptured and significant actions were performed to decrease the chances of his developing peritonitis. Upon arrival to your unit, you perform your initial assessment, including the wound site. After completing your assessment and performing the immediate postoperative orders the health care provider wrote, you return to offering nursing care to the rest of the patients on your team. (Learning Objectives 2 and 8)
a. Which topics would you expect to include in your documentation from this case?
b. When would you expect to record your documentation?
c. How often would you collect data (perform assessments) from the patient?
d. Where would you expect to find pertinent information regarding the patient’s surgery and interventions performed during surgery?
e. Regarding confidentiality, what information can be shared with classmates? Describe the criteria and purpose for sharing patient information with others.
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