Documentation Flashcards
1
Q
What is the purpose of a legal record?
A
- verifies need for care
-nurses held accountable for actions
-can be used in court
2
Q
What is a source record?
A
separate section for each discipline
3
Q
What is a clinical/critical pathway?
A
only charts deviations from the pathway
4
Q
When taking notes what is the DAR method?
A
Data, Action, Response
5
Q
When taking notes what is the PIE method?
A
Problem, Intervention, Evaluation
6
Q
When taking notes what is the SOAP method?
A
Subjective, Objective, Assessment, Plan
7
Q
What can be included on a omitted care document?
A
incident reports
