Common Formats Flashcards
1
Q
Narrative
A
written in order of patient experience happens.
Provides details of patient’s care, status, activities, nursing interventions, psychosocial context and response to treatment.
Charting by Exception
2
Q
Problem-Intervention-Evaluation (PIE)
A
Nursing focused instead of medical focused and eliminates need for separate care plan
3
Q
Soap/Soapie/Soapier
A
Subjective data, objective data, assessment, plan, intervention, evaluation, revision
4
Q
DAR
A
Data, action, response
