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6 Cards in this Set
- Front
- Back
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Documentation |
Any Written or printed information relied upon as a legal record of proof related to client care |
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Factual |
Descriptive, objective, information of what nurse see's, heard, feels, and smells. |
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Accurate |
Using exact measurement ensures a record is accurate and not ambiguous |
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Complete |
Information recorded contains thorough, concise, application client data |
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Currebt |
Timely as close as possible to time of event/activity |
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Organized |
Presented in a logical sequence |
