Documentation Flashcards
- it is an informal oral communication
- has two or more health care personnel to identify problem or establish strategy for a problem
Discussion
- can be oral, written, or computer based communication
- convey info to the next shift to help them prepare
Report
- a formal legal document
- provide evidence of clients care
- format depends on hospital
- must be protected
Client’s Chart or Client’s Record
- a.k.a charting
- process of making an entry on client record
Purpose
* communication
* planning client care
* auditing health agencies
* education
* reimbursement
* legal documentation
* Health care analysis
Recording
- traditional part of source oriented recording
- consists of written notes which includes routine care, normal findings, and client problems
Narrative Charting
Format of Charting
- makes client and client’s concerns focus of care
- provides holistic perspective of client and client needs
Focus Charting Format or F-DAR
F-DAR
Focus
Data
Action
Response
F-DAR
- condition, nursing diagnosis, behavior sign or symptoms, acute change on clients condition or client’s strength
- concern is the patient
Focus
F-DAR
- reflects assessment phase
- supports focus or problem
- consists observations of client status and behaviors
- records both subjective and objective data
Data
F-DAR
- reflects planning and implementation
Action
Method of Charting
- uses SOAP or SOAPIER format
Progress Notes
F-DAR
- reflects evaluation phase
- describes client’s response to any nursing and medical care
Response
SOAPIER
Subjective Data
Objective Data
Assessment
Plan
Intervention
Evaluation
Revision
SOAPIER
- info obtained from what the client says
- describes client’s perceptions and experience with the problem
Subjective Data
SOAPIER
- info measured or observed using the five senses
Objective Data
SOAPIER
- interprets or conclusion about subjective and objective data
- initially statement of problem
- clients condition and progress level
Assessment
SOAPIER
- plan of care to resolve stated problem
Plan
SOAPIER
- specific care given to solve problem from planning
Intervention
SOAPIER
- response of patient
- answers question if goal was met
- primarily reassessment of data
Evaluation
SOAPIER
- plan and modification suggested by evaluation
Revision
