Documentation Flashcards
Informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
Discussion
Is oral, written or computer-based communication intended to convey information to others.
Report
Formal, legal document that provides evidence of a client’s care
Chart/Client Record
Recording a.k.a?
charting/ documenting
Process of making an entry on a client record
Recording
Purposes of Records
- Communication
- Planning client care (NCP)
- Auditing health agencies
- Research
- Education
- Reimbursement
- Legal Documentation
- Healthcare analysis
A traditional part of source-oriented record
Narrative Charting
it consists of written notes that include routine care, normal findings and client problems
narrative charting
ROM =
range of motion
Intended to make the client and client concerns the focus of care
Focus Charting
Provides a holistic perspective of the client and the client’s needs
Focus Charting
May be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or client’s strength
Focus
Reflects the assessment phase of the nursing process and consists of observations of client status and behaviors
Data
Reflects planning and implementation\ and includes immediate and future nursing actions
Action
Reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care
Response
FDAR meaing
Fcous, Data, Action. Response
Consists of information obtained from what the client says. It describes the client‘s perceptions and experience with the problem
Subjective Data
Consists of information that is measure or observed by use of the senses
Objective Data
Interpretations or conclusions drawn about the subjective and objective data; initially, it is the statement of the
problem
Assessment
it should describe the client’s condition and level of progress
Evaluation
The plan of care designed to resolve the stated problem
Plan
Refer to the specific interventions that has been performed by the caregiver
Interventions
Includes client’s responses to nursing interventions and medical treatments. This is primarily reassessment data.
Evaluation
reflects care plan modification suggested by the evaluation
Revision
