Terminal illness is an increasing possibility as incarcerated persons age and remain in custody. This can be a time of great sorrow, loneliness, suspicion, pain, and suffering for incarcerated individuals. They may have great fear of dying alone, in pain and without support. Every correctional facility will inevitably have an incarcerated individual who is diagnosed with a terminal condition. Are…
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This post continues our series on Documentation for Correctional Nurses with a discussion of electronic health records. The Electronic Health Record Today, many systems are using an electronic health record (EHR). The benefits of an EHR include improved legibility, improved efficiency, and improved availability of patient information to all staff. The clinical decision support included in most EHRs today allows…
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In this post, we continue our discussion of documentation with methods of documentation. Methods of Documentation: Narrative Note In narrative documentation, a summary of the care provided is written in paragraph form. The patient’s status should be described in detail, as well as all treatments and nursing interventions performed and the patient’s response to those interventions. Narrative notes may often…
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