The purpose of medical documentation and monitoring is to track the patient’s progress and plan their care accordingly. This documentation can include a complete medical history, physical examination, medical review, diagnosis, and medical treatment plan.
Improving Rounding Practices with Technology – Nurse Rounds, Vitals Documentation and Detox Score Assessments with ObservSMART
Current issues in psychiatric care settings often include missed or falsified observations on patients, or what is often referred to as a Q15 check. Although this can be affected by many factors, it is extremely dangerous to patients, staff, and the organization overall.