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Nursing Manual Nursing Documentation A person's health care record provides legal proof of the nature and quality of care that the person receives.A well documented health care record
There is no specific requirement for the frequency of entries. Rather, they are made as health issues arise. Most importantly, when someone identifies a health problem, the progress notes need to include interventions and state the problem's resolution. OAR 309-049-0075 4(d) states: "The program shall monitor the health status and physical conditions of individuals and take action in a timely manner in response to identified changes in conditions that could lead to deterioration or harm." The progress notes are a primary reference source for determining if timely intervention has occurred. It is often the RN who follows up on all progress notes made by direct care staff. This follow up can include an assessment of the problem, interventions used or planned and a record of the resolution to the health concern. It is suggested that progress note entries be available in the current record for the past six months. In addition to the progress notes, data may be recorded on various flow sheets (e.g., vital signs, IO, weights, menses, seizures, telephone communication note etc.) |
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