Documentation
Help!
|
|
||||
|---|---|---|---|---|---|
| show | The Process of preparing and recording all pertinent observations, interventions and responses relating to the complete record of a client's care; vital tool for communication among health care team members facilitates care
🗑
|
||||
| show | Communication, Care planning, Legal documentation, Education, Research, Quality review Reimbursement
🗑
|
||||
| show | Documentation of Care, Nursing Interventions, Patient Responses
🗑
|
||||
| show | Agency policies govern method and frequency of charting used and who can write on the record Content should be accurate, concise, complete, relevant, sequential, orderly and factual, Format uses correct spelling, grammar, terminology
🗑
|
||||
| Guidelines for Documentation | show 🗑
|
||||
| show | Source Oriented Records, Problem Oriented Medical Records, SOAP, (SOAPIE, SOAPIER)PIE, Focus Charting (DAR)Charting by Exception, Case Management Model
🗑
|
||||
| Source Oriented Charting: Narrative | show 🗑
|
||||
| Problem Oriented Medical Records (POMR) | show 🗑
|
||||
| show | Subjective Data, Objective, Data, Assessment, Plan, Implementation, Evaluation, Response/Revise
🗑
|
||||
| show | S: patient states "my leg hurts", O: red open area observed on leg with purulent drainage, A: wound infection continues, P: clean wound and cover wtih a dressing, I: wound cleaned with NS and dry dressing applied, E: pt. states leg feels better, R: will m
🗑
|
||||
| PIE: Problem, Intervention, Evaluation | show 🗑
|
||||
| show | Data, Action, Response, D - Pt. holding head and complaining of headache as 8 on 0 to 10 scale, A - Adminstered Tylenol 650 mg p.o. 1000, R - 10:30 am. pt. states pain decreased to 4 on 0 to 10 scale and is smiling
🗑
|
||||
| show | Assumption: all predetermined standards are met w/normal resopnse unless documented; Eliminates lengthy and repetitive narrative notes; Emphasizes only significant data & makes it easy to retrieve; Improved tracking of important patient responses
🗑
|
||||
| show | Case manager is responsible for planning, coordinating care and consulting with other health care team members to ensure that patienTs are discharged in a timely manner; Focuses on care during an entire episode of illness across every setting where patien
🗑
|
||||
| Computerized Records | show 🗑
|
||||
| Nursing Documentation Formats | show 🗑
|
||||
| show | Nursing Care Plan; Nursing diagnoses, goals/outcomes, actions; Standardized but individualized for each patient; Critical Pathways; Charting is focused on expected outcomes for each day of care
🗑
|
||||
| show | Progress Notes; informs care givers of the progress patient is making toward achieved expected outcomes; Discharge or transfer summary; Reason for treatent, patient condition, level of goal achievement, instructions for continued care; Home health or Long
🗑
|
||||
| show | Usually check off or fill in blank; Graphic/Clinical record, Vital signs, weight, BM's, I&O; 24-hour fluid balance record, intake and otuput per shift and total 24 hours; Medication adminstration Record, Records all medications given to patient, includes
🗑
|
||||
| show | Follow guidelines for documentation; Must also be legible; Chronological order, no blanks; Blank ink, no erasure or white out; Documentation is best legal defense
🗑
|
||||
| Rule of Documentation | show 🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
howardccnurs
Popular Nursing sets