Chapter 7 Fundamentals Flashcards
Charting
Documentation is used to track the application of the nursing process. The nurse writes down observations made about the patient notes the care and treatment that was delivered and adds the patient responses
Case management system charting
Which tracks variances from the clinical pathway
Charting by exception
Which focuses on deviations from predefined norms using presets protocols and standards of care
Computer assisted charting
Where data are input to the computer
Computerized provider order entry CPOE
Provides for efficient workflow because when orders are entered into the computer they are automatically routed to the appropriate clinical area for action.
Electronic health record EHR
Is a computerized comprehensive record of a patient history and care across all facilities and admissions
Focus charting
Which centers on the patient from a positive perspective
Medical records chart
The medical record contains all orders test treatment and care that occurred while the person was under the care of the healthcare provider.
Pie charting
Stands for problem identification, interventions and evaluation. This type of care follows the nursing process and uses nurses diagnosis wow placing the plan of care within the nurses progress notes. Differs from soap notes because it is not use traditional nursing care plan or acquiring or two charting of the assessment as long as they are normal
Problem oriented medical record charting POMR
Focuses on the problem the patient experiences as a result of being ill.
Protocols
Standard procedures and standards of nursing care are the heart of the system
Source oriented Narrative charting
Is organized by source or author of the charting entry
