Recordkeeping in nursing

Overview[ edit ] Origin of term[ edit ] U. The word is linked to the use of a whistle to alert the public or a crowd about a bad situation, such as the commission of a crime or the breaking of rules during a game. The phrase whistle blower attached itself to law enforcement officials in the 19th century because they used a whistle to alert the public or fellow police. By the yearthe phrase had become a hyphenated word, whistle-blower.

Recordkeeping in nursing

Any additions will be posted on this site immediately. Administration of Immunizations The non-patient specific standing order and protocol must be authorized by a physician or a certified nurse practitioner. RNs must maintain or ensure that a copy of the standing order s and protocol s authorizing them to administer immunizations is maintained.

All RNs immunizing children in accordance with non-patient specific standing orders and protocols must be employed by, or act as an agent of, the Visiting Nurses Association or an equivalent organization legally authorized to provide nursing services as determined by the New York State Education Department or by a State, county, municipal or other government agency.

Recordkeeping in nursing

An LPN can assist in administering immunizations give the injection, assist in recordkeeping, and when appropriate, administer anaphylactic agents as long as the RN assesses the recipient, and is responsible for the on-site direction of the LPN in administering the immunizations.

Epidemics Any RN may administer any immunizing agent that is authorized by a non-patient specific standing order and protocol as part of an immunization program authorized, maintained or under the auspices of the State Commissioner of Health, a county commissioner of health, or a county public health director when the immunization program is instituted as a result of an epidemic declared by any of these public health officials.

Staff development or inservice departments that train individuals in CPR but do not necessarily provide "certification" are considered equivalent organizations by the Department.

Protocol Requirements Ensure that the potential recipient is assessed for contraindications to immunizations; Inform each potential immunization recipient of the potential side effects and adverse reactions, orally and in writing, prior to immunization and inform each potential immunization recipient, in writing, of the appropriate course of action in the event of an untoward or adverse event.

Obtain consent for the immunization from the potential recipient, or from a person legally responsible in the case of a minor or otherwise incapable person, before the immunization is administered.

In cases of minors and persons incapable of personally consenting to immunization, consent may be gained by informing the legally responsible person of the potential side effects and adverse reactions in writing and obtaining a written consent prior to administering the immunization.

Provide to each legally responsible immunization recipient, a signed certificate of immunization noting the recipient's name, date of immunization, address, immunization agent, administering nurse, immunizing agent, manufacturer and lot number, and recommendations for future immunizations.

Communicate the information provided to the recipient to the recipient's primary care provider PCP if there is one. For the administration of the influenza vaccine to adults only, acceptable practices include such examples as having a patient fill out a postcard that the nurse or agency can send to the primary care provider or having a patient sign a consent form on the certificate of immunization agreeing to provide the primary care provider with a copy of the certificate listing the immunization provided.

Have available on site, agents to treat anaphylaxis including, but not limited to, epinephrine and necessary needles and syringes. Ensure that the record of all persons immunized includes: For the administration of the influenza vaccine to adults only, it is acceptable to maintain a log of the names, addresses and phone numbers of all adult patients, immunized with the influenza vaccine under non-patient specific orders in a dated file with a copy of the influenza order and the influenza protocol attached to the log.

Ensure that a record is kept of all potential recipients, noting those who refused to be immunized. Anaphylaxis Administration Requirements Non-patient specific standing orders and protocols must be authorized by a physician or a certified nurse practitioner.

RNs must maintain or ensure the maintenance of a copy of the standing order s and protocol s authorizing them to administer anaphylactic treatment agents. Arrange for appropriate follow up by contacting the local emergency medical services system EMS following administration of anaphylactic treatment agent sor ensure that equivalent follow up is provided through other arrangements.

Report to EMS or other follow up care providers which anaphylactic treatment agent s was administered, the time administered, the dose, strength and route of administration.

NYS Nursing:Practice Alerts & Guidelines:RN & LPN Practice Issues:Immunization Guidelines

RNs must maintain or ensure the maintenance of a copy of the non-patient specific order s and protocol s authorizing them to administer the PPD mantoux tuberculin skin test. PPD Protocol The RN shall ensure that each potential recipient is assessed for untoward conditions that would preclude purified protein derivative PPD mantoux skin testing and that the patient's exclusion from the test is documented.

Ensure that a patient's refusal to be tested is documented. Ensure that a record is kept of all persons who received the PPD including, but not limited to: The RN shall be responsible for having an appropriate non-patient specific order for anaphylactic agents, the agents and syringes and needles available at the PPD testing site except in an emergency.

Recordkeeping in nursing

The actual PPD may be administered only after the recipient has been informed in writing as to the side effects, potential adverse effects of the test and consented to receive the test.

The RN will communicate results to the patient's primary health care provider if there is one. The RN will maintain or ensure maintenance of a record of each person PPD tested in accordance with The description of the results of a PPD skin test must be communicated to the RN and the RN makes the positive or negative call and resulting care plan.

Failure to adhere to any requirement prescribed in section The sale of these immunization agents and needles and syringes may be considered a wholesale transaction. A wholesale registration from the State Board for Pharmacy will not be necessary for either of these transactions.

The non-patient specific standing order and protocol must be authorized by a physician or a certified nurse practitioner. Non-patient specific standing orders for immunizations must contain the following: Records of medications provided must be maintained for six years or as otherwise provided by law.The median annual wage for nursing assistants was $27, in May The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less.

Licensed Professions: Nursing. * The Board of Regents may add immunizing agents in accordance with the recommendations of the Centers for Disease Control and Prevention and the New York State Department of Health. A whistleblower (also written as whistle-blower or whistle blower) is a person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization that is either private or public.

The information of alleged wrongdoing can be classified in many ways: violation of company policy/rules, law, regulation, or threat to public interest/national.

Search form

If it's important enough to do, it should be important enough to record and report. Resources on how to keep track of what's meaningful to understand volunteer contributions, including use of computer software designed for this purpose. Smart nursing with Nuance’s clinical documentation in nursing record keeping Record keeping for nurses needs to be high quality, timely and standardised with inbuilt levels of security, governance and control as appropriate for each patient scenario.

Guidelines for continuing professional development Page 3 of 4 • in-service education • attending conferences, workshops and seminars.

Maintaining best practice in record-keeping and documentation