concepts test chapters 7-10 vocab and other info Flashcards
medical record (chart)
contains all orders, tests, treatments, and care that occurred while the person was under the care of the health care provider. It is a communication tool.
charting is what?
it is also known as documentation. it is used to track the application of the nursing process. the nurse writes down observations made, notes the care and treatment that was delivered, and add’s the patients response.
confidential
this means you can only give out information with the patients consent, since the chart contains personal info.
the six main methods of charting are?
- source-orientated (narrative) charting.
- problem orientated medical record POMR charting
- focus charting
- charting by exception
- computer- assisted charting
- case management system charting
what do flow sheets track?
routine assessments, treatments, and frequently given care.
source orientated charting
records organize according to the source of the information. there are separate forms for physcians, dentists, nurses. information is shown in chronological order. they follow a body system format.
advantages and disadvantages of the source orientated charting
adv: it gives information on the patients condition and care in chronic order. it indicates the patients baseline condition for each shift. it includes aspects of all steps of the nursing process.
disadv. it encourages doc of both normal and abnormal findings, making it difficult to separate. It requries extensive charting time by staff. It discourages physcians and other health team members from reading all parts of the chart.
Problem Oriented Medical Record POMR
contains five basic parts: the database, the problem list, the plan, the progress notes, the discharge summary. it focuses on patient status, emphasizing the problem solving approach to patient care an providing a method for communicating what, when, an how things are to be done to meet patient’s needs.
advantages and disadvantages of POMR
adv: it provides doc of comprehensive care by focusing on patients and their problems. promotes problem solving approach to care. improves continuity of care. easy auditing.
disadv: loss of chornic charting. it is more difficult to track trends in patient status. it fragments data
PIE charting
Problem identification, Interventions, Evaluation. this type of charting follows the nursing process and uses nursing diagnoses wile placing the plan of care within the nurses progress notes.
Focus Charting
it is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event. Three Components: Data, Action, Response. DAR or DAE; evaluation.
advantages and disadvantages of Focus Charting
adv. it is compatible with the use of nursing process. it shortens charting time. the focus is not limited to patient or nursing dignosis.
disadv: if the database is not complete, patient problems may be missed. It does not adhere to charting with the focus on nursing diagnosis and expected charting.
charting by exception
is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. if it wasnt charted it wasnt done. needs to be charted.
advantages and disadvantages of charting by exception
adv: it highlights abnormal data and patient records. it decreases narrative charting time. it eliminates duplication of charting.
disadv: it requires development of detailed protocols and standards. nurses become so use to not charting some things can be missed .
protocol
standard procedures
computer assisted charting
fha
electronic health record
is a computerized comprehensive record of a patients history and care across all facilities and admissions.
CPOE
Computerized provider order entry provides for efficient work flow because, when orders are entered into the computer, they are automatically routed to the appropriate clinical areas for action.
case management system charting
a method of organizing patient care through an episode of illness so that clinical outcomes are achieved within an expected time frame and at a predictable cost.
when charting, what do you chart relating to time
only chart what you have done for the patient, never what you plan on doing.
the kardex what is it
is a quick reference for current info about the patient and ordered treatments, updated daily.
what information does a kardex contain
room number, patient name, age , sex, admitting daignosis, and physic name. date of surgery type of diet scheduled tests level of activity permitted tubes, machines in use nursing order for assitive or comfort measures names of meds iv fluids
types of information to be documented
admission note asessment data for all body systems body care death degree of activity, diagnostic tests diet and fluids discharge from the facility dressing and wound care i and o IV meds mental state and mood oxygen in use postoperative care sleep teaching postiion travel tubes visitors
communication
occurs when one person sends a message to another person who receives it, processes it, and indicates that the message has been interpreted.
