Question

Identify guidelines for effective recording that meets legal and ethical standards.

Answer 1

Ans )Guidelines for effective recording that meets legal and ethical standards:

- Client's record is a legal document
- May be used to provide evidence in court.

• Factors to Consider in effective recording that meets legal and ethical standards.

- Timing
- Legibility
- Permanence
- Accepted terminology
- Correct spelling
- Signature
- Accuracy
- Sequence
- Appropriateness
- Completeness
- Conciseness
- Legal prudence

• Essential guidelines for reporting client data:

- Should be concise, including pertinent information but no extraneous detail

• Types of reporting:

- Change-of-shift report
- Telephone reports
- Care plan conference
- Nursing rounds
- SBAR:

S-Situation: Briefly describe the situation. Give a succinct overview
B-Background: Briefly state pertinent history. What got us to this point?
A-Assessment: Summarize the facts. What do you think is going on?
R-Recommendation: What are you asking for? What needs to happen next?