首页   按字顺浏览 期刊浏览 卷期浏览 Defensible Documentation Using the Endoscopy Pathway
Defensible Documentation Using the Endoscopy Pathway

 

作者: Phea Anderson,   Jennie Rodlund,  

 

期刊: Gastroenterology Nursing  (OVID Available online 1999)
卷期: Volume 22, issue 2  

页码: 38-46

 

ISSN:1042-895X

 

年代: 1999

 

出版商: OVID

 

数据来源: OVID

 

摘要:

Complete, defensive documentation in a busy endoscopy unit can be elusive. Quick runaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.

 



返 回