The nursing staff is often referred to as the "eyes and ears" for the physician and other members of the health care team because it spends more time with patients/residents than any other discipline. Much of the data in the medical record is generated by the nursing staff from the initial health assessment, which includes a nutrition screen to obtain information regarding weight; intake of meals, tube feeding, and parenteral nutrition; fluid intake and output; bowel movements; skin breakdown; self-feeding ability; administration of medications, treatments, and supplements; and daily accounts of changes in condition as well as tolerance to the current regimen. One must realize that much of the data are collected by certified nursing assistants (GNAs) and entered into the medical record by them or unit nurses. And the entire health care team depends on them for complete and accurate documentation in accordance with health care codes.
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