Documentation Flashcards
SOAP/SOAPIE/SOAPIER
•Subjective & Objective data
•Assessment
•Plan
•Intervention
•Evaluation
•Revision
Kardex
•summary worksheet reference of basic info
-patient data
-medical diagnoses
-allergies
-code status
-medical orders
-activities permitted
DAR
-data
-action
-response
Report and document
-signs & symptoms
-nursing care rendered
-administration of medications
-client responses
-healthcare team members
Signs are
Objective (fact)
Purpose of medical records
-communication
-monitoring
-education
-research
-continuity of care
-reimbursement compliance
The chart is a
-witness
-a detailed account of the real time facts
Documentation should be
-factual
-accurate
-complete
-current
-organized
*no assumptions or opinions
Symptoms are
Subjective (use quotations)
Accurate
-exact measurements
-clear
-understandable
-correct spelling
-standard abbreviations only
-timed, dated with signature and credentials
Factual
-objective
-subjective
-descriptive
Complete
-condition change (onset, duration, location, description)
-do not leave blanks (use N/A)
-communication with patient and family
Current
-real time or ASAP
-time of occurrences
-military time
-never pre-time, pre-date, pre-chart (this is illegal falsification of record)
Organized
-chronological order
-clear
-concise
-complete sentences not needed
The chart must reflect an accurate, clear, and comprehensive picture of:
-patients needs
-nurses interventions
-patient outcome
Avoid terms like:
-accidentally
-apparently
-appears
-assume
-confusing
-could be
-may be
-miscalculated
-mistake
-somehow
-unintentionally
-normal
-good
-bad
Narrative
-written in order of patient experiences
-details patients care, status, nursing interventions, activities, psychosocial context & response to treatment
PIE
Problem
Intervention
Evaluation
-nursing focused vs medical focused
-eliminates need for seperate care plan
Communication
-multi-disciplinary
-critical for continuity of care and risk reduction
Documentation
-who
-what (complaint, care provided)
-when (time)
-where (where was treatment/meds given)
-how (how was treatment completed & how did the pt tolerate it)
-outcome
Documentation “don’t”
-don’t document a patient problem without charting what you did about it
-don’t alter a patients record
-don’t write imprecise descriptions
-don’t what what someone else heard, felt, or smelled
Documentation
Paper Charting
-print or cursive
-legible
-blue or black ink
-NEVER use white-out
-NEVER use erasable ink
-NEVER obliterate
-NEVER erase- NO pencils
Flow Sheets
-Columns for recording dates and times of related assessment and intervention information:
•vital signs
•intake and output
•assessment
