Documentation Flashcards
documentation or reporting: proves care was provided
documentation
documentation or reporting: verbal sharing of info about patients with another person or persons
reporting
documentation or reporting: includes all assessments
documentation
documentation or reporting: uses SBAR
reporting
nursing functions of patient health record (3)
communication, assessment, care planning
non-nursing functions of patient health record (5)
legal document, quality assurance, reimbursement, research, education
conditions that aren’t reimbursed
nosocomial infections, foreign object retained after surgery, severe pressure ulcers, falls, central line or urinary catheter infections (“never events”)
computerized way to compile patient data
electronic health record (EHR)
major functions of EHR software
computerized physician order entry, electronic med admin, clinical decision support
documentation elements (5)
confidentiality, accurate, concise/complete, objective, organized and timely
don’t batch chart!
types of documentation records (6)
admission entry/assessment flow sheet: vitals, assessment, lab data plan of care: care plan, concept map clinical pathway nursing discharge summary nursing progress notes
types of nursing progress notes (4)
Narrative, SOAP, PIE, FOCUS
SOAP
subjective - patient expresses
objective - vital signs, lab data
assessment - a “conclusion”
plan - nursing interventions used to address conclusion
disadvantage: problem focused
PIE
Problem: nursing diagnosis
Intervention
Evaluation
disadvantage: not interdisciplinary
Focus (DAR)
Focus in one column, then:
Data
Action
Response
disadvantage: not interdisciplinary
