Assignment Task
Documentation is an essential component of effective communication. As student Registered Nurses and Registered Nurses, we need to ensure that relevant, accurate, complete and up-to-date information about a patient’s care is documented, and members of the health care team have access to the right information to make safe clinical decisions and to deliver safe, high-quality care.
Please refer to the case information provided in the subject Interact2 site. The case information includes a primary and secondary survey and an image of a wound.
This task asks you to review the case information and complete the following:
Complete an assessment of the wound in the provided case scenario using the Bates-Jensen Wound Assessment Tool.
You do not need to include this form as part of this task, but will need to refer to it comprehensively as part of your response to the next part of the task.
Clinical Progress Note
1. Document all the findings of the primary and secondary survey and the wound assessment in the form of a typed Clinical Progres
A structured framework should be applied to support the Clinical Progress Note. Guiding principles for high quality documentation as outlined in the subject learning modules should be incorporated: person-centred, compliant, complete and accurate, integrated and up to date, accessible, readable and enduring. References would not usually be expected in this section.
2. Outline in the Clinical Progress Note one SMART goal, based on the clinical information you have reviewed
Underneath the Clinical Progress Note, address the following:
Describe how your Clinical Progress Note complies with legal and professional requirements, including the guiding principles for high-quality documentation: person-centred, compliant, complete and accurate, integrated and up to date, accessible, readable and enduring. References should be included to support this discussion.