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Documentation-P&P
NU110
Question | Answer |
---|---|
Malpractice mistakes that are common on charting failing to: | 1) record pertinent health/drug info 2) record nursing actions 3) record meds given 4) drug reactions or changes in clients condition 5) writing illegible or complete records 6) to document a discontinued medication |
purposes of records | 1) communication 2) legal documentation 3) financial billing 4) education 5) research 6) auditing-monitoring |
Confidentiality | 1) pt. educ. on privacy protection 2) ensuring pt. access to their medical records 3) rcing pt. consent before info is released 4) providing recourse if privacy protection are violated |
quality of documentation | factual, accurate, complete, current, organized |
SOAP | subjective, objective, assessment, plan |
SOAPIE | subjective, objective, assessment, plan, intervention, evaluation |
PIE | problem, intervention, evaluation |
Focus charting - DAR | data, action, response |
Problem-Oriented Medical Records (POMR) | database, problem list, nursing care plan, progress notes |
Organization of Traditional Source Record | -Admission sheet -Physician's order sheet -Nurse's admission assessment -Graphic sheet & flow sheet -Medical history & examination -Nurses' notes -medication records -Physician's progress notes -health care disciplines' records -discharges summar |
SBAR | Situation, Background, Assessment, Recommendation |