Ch. 5 Documentation Flashcards
charting by exception
a type of charting in which only variances from “normal” in all activities of daily living, vital signs, and assessment findings are charted as entries
-designed to drastically reduce time spent completing paperwork; however, opinion vary about its efficacy and safety
confidentiality
the maintenance of privacy by not sharing with a third party privileged or entrusted information
documentation
the act of charting or making written notation of all the things are pertinent to each patient for whom a nurse provides care
electronic health record
a computerized database that typically includes present and past medical and surgical information, laboratory information, radiographic information, & drug info. about a patient; most also contain billing and insurance info. as well
focus charting
a type of charting that is focused on the patient and patient concerns, problems, & strengths.
- Unlike PIE charting, there is not a constructed list of specific problems
- includes data, action, and response
Kardex
a type of flip chart with a page for each patient on the unit/floor that contains a summary of care required by the patient; it requires continual updating and maintenance by nursing staff
narrative charting
type of charting that details the patient’s experiences during a hospital stay. it is written in chronological order & relates to the patient’s health status through admission and through changes in condition, up to and including their discharge status
PIE charting (problem, intervention, evaluation)
type if charting style that is shorter and documents fewer data than the SOAPIER charting style
- only addresses the patient’s problems; therefore concept of treating the patient is holistically lost
SOAPIER charting
one of the lengthier documentation formats that typically is used in progress notes and the nurse’s notes
- includes subjective data; objective data; assessment data: a plan: intervention: evaluation; and if needed a revision
