Patient's access to personal online health records a first! - page 2

Hmmm this is interesting...I can see the benefits and cons to this already! I can defintely see where non medical trained patients will get confused/overwhelmed with ultrasounds, ct scans results,... Read More

  1. by   ChristineN
    Quote from studentpn73
    Just learning proper charting at the moment so please correct me if Im wrong!!
    From my understanding we wouldn't use "non-compliant" in describing a clients behaviour would we?
    Wouldnt we as nurses use something more along the lines of "Client stated "I want to be left alone" when writer went to help with ADL" so that when Sally Jones reads her charts, or if Sally's charts are ever used in Court, then there is nothing insulting to her character?

    Again please please correct me if I am wrong...just a student sooo
    Use the word "non-compliant," perhaps not, but I have been known to articulately describe a pt's drug seeking behaviors in detail in my nurse's notes, as well as any behaviors in which the pt is refusing medical treatment.