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Scene: A nurse has a rest and makes a short conversation with Chika in cafe. Chika wants to know nurses activities in hospital.

Dina Chika Dina Chika Dina Chika Dina Chika Dina Chika Dina

Chika Dina Chika

: Hi Chika. How are you : Hi Dina. Im fine and you : Im fine! too. "h! its nice to see you here. : Its my place to have a rest while having lunch. : " yah. #ut I never see you here. : I always come when they leave this place! so I can freely en$oy my %unch. : " I see. #ut Its different from me. I must &e on time &ecause I am responsi&le with my patients. : #y the way. 'hat do you do every day : I always wake up at ( oclock in the morning. )hen I prepare anything to go to the hospital. "f course! I often have &reakfast &efore going to work. 'hen I have morning shift I come to the hospital &efore * a.m. : 'hat do you do then : "f course! I handle the patients from my friend who has night shift. )hen I do nursing procedures like taking patients &lood pressure! giving medicine! changing infusion and reporting to the doctor. )his is my daily routine in hospital. 'hat a&out you! Chika : In my office! the work &egins at + oclock a.m. and finishes at ( p.m. ,o! Im not in a hurry. In office! when my work is complete I always make a chat with my friends. : " yah Chika! thank you for you time! I have to visit my patients. : -oure welcome. I hope we can meet here at any time.



9 )o provide a complete nursing record! you must determine what information to include in your charting. )his is a comple/ responsi&ility! and one in which you will &ecome more skilled with e/perience. -ou must try to provide a clear! accuracy and clarity record of the nursing process in relation to the individual patient. )he nur ing !roce as a framework to guide your review and help you identify the relevant information includes aspects of assessment! nursing diagnosis or analysis! planning! intervention or implementation! and evaluation. A e "ent #ata include &oth su&$ective and o&$ective information. )he record assessment data reflect findings that relate to the patients reason for &eing hospitali0ed! any a&normal findings and normal findings that relate to previously noted pro&lems! and information significant to the patients nursing diagnoses! specific pro&lems! or medical diagnoses. In addition to these data! you must also record your analysis to indicate any new pro&lems identified. )hese may &e recorded as a new nur ing #iagno e colla&orative pro&lems! or general pro&lems the have not yet &een categori0ed. Planning is recorded on a separate nursing care plan! which is then included with the rest of a patients record at the time of discharge planning information may also include referrals made to other healthcare providers! such as the patients physician or the respiratory therapist. Inter$ention or i"!le"entation data include nursing actions that are taken in response to an e/isting nursing diagnosis and measures taken to prevent pro&lems. E$aluation data document the effectiveness of nursing and all other actions and therapies. )hese data identify the patients progress toward the desired out comes of care. )hey are vital for determining whether care has &een effective and for planning future care. As a legal record! a charting must conform to certain legal standards of legi&ility! clarity! and accuracy. All entries in a paper chart must &e in in% so that changes are noticea&le and the record is permanent. -our facility may specify a particular colour of ink &lack 1 &lue to &e used. %egi&ility is critical2 o&viously statements that are not legi&le are not usa&le either for care or in court. Computeri0ed patient records maintain this legal standard &y not permitting changes once the information has &een entered into the record. If you make an error! draw a single line through the incorrect entry so that it remains legi&le. )raditionally the word 3error4 followed &y initials 5or first initial! last name! and title6 was written a&ove the lined 7 out entry. 8rasing or using correction fluid should never correct documentation errors. )his may create the impression that the information recorded was damaging to the care provider or is &eing hidden for other reasons. 'hen the mistake can &e clearly read! the situation can &e evaluated more readily.

= 'hen you ign a notation on a patients record! use your first initial and full last name followed &y the a&&reviation of your position. :ursing students used the a&&reviation :, 5nursing student6! ;: for ;egistered :urse and :A for :ursing Aid. <low sheets are often signed once per shift in a designated signature section where the signature and the initials are documented together. Do a &inal el&'chec% such as legi&ility! completeness! correct format! date! time and signature.

Answer the questions verbally .. 9. =. >. (. 'hy the charting must follows the nursing process 'hat will you do! if you make an error on your charting 8/plain the steps of charting 'hy all entries in a paper chart do must &e in ink 'hat do think a&out computeri0ed patient records means all charting or patients documentation using a computer

True or False .. 9. =. >. (. :ursing Aid and ;egistered :urse has the same responsi&ility in giving service to patients <inal self?check always done &y a nurse in?charge If you carried out a doctor orders! and the order not understanda&le! you can ignore it and let it done &y another senior nurse If you receive a telephoning orders from doctor! you may carried out and write a &rief note to remind doctor to give a signature later on. It is important to ask special cases! special medicines when you receive 8ndorsement patient from the nurse duty &efore

Memori0e and write in sentences all these voca&ularies @ive ,tart Handover ,tat 8ndorse Duty Determine Arepare Charting ;eceive ;emind ;eport Inform Carry out )ake care

E. TASK Aractice in group and make conversation a&out daily activities at home! campus or hospital.