Documentation Flashcards

1
Q
  • it is an informal oral communication
  • has two or more health care personnel to identify problem or establish strategy for a problem
A

Discussion

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2
Q
  • can be oral, written, or computer based communication
  • convey info to the next shift to help them prepare
A

Report

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3
Q
  • a formal legal document
  • provide evidence of clients care
  • format depends on hospital
  • must be protected
A

Client’s Chart or Client’s Record

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4
Q
  • 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

A

Recording

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5
Q
  • traditional part of source oriented recording
  • consists of written notes which includes routine care, normal findings, and client problems
A

Narrative Charting

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6
Q

Format of Charting
- makes client and client’s concerns focus of care
- provides holistic perspective of client and client needs

A

Focus Charting Format or F-DAR

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7
Q

F-DAR

A

Focus
Data
Action
Response

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8
Q

F-DAR
- condition, nursing diagnosis, behavior sign or symptoms, acute change on clients condition or client’s strength
- concern is the patient

A

Focus

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9
Q

F-DAR
- reflects assessment phase
- supports focus or problem
- consists observations of client status and behaviors
- records both subjective and objective data

A

Data

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10
Q

F-DAR
- reflects planning and implementation

A

Action

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11
Q

Method of Charting
- uses SOAP or SOAPIER format

A

Progress Notes

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11
Q

F-DAR
- reflects evaluation phase
- describes client’s response to any nursing and medical care

A

Response

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12
Q

SOAPIER

A

Subjective Data
Objective Data
Assessment
Plan
Intervention
Evaluation
Revision

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13
Q

SOAPIER
- info obtained from what the client says
- describes client’s perceptions and experience with the problem

A

Subjective Data

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14
Q

SOAPIER
- info measured or observed using the five senses

A

Objective Data

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15
Q

SOAPIER
- interprets or conclusion about subjective and objective data
- initially statement of problem
- clients condition and progress level

A

Assessment

16
Q

SOAPIER
- plan of care to resolve stated problem

A

Plan

17
Q

SOAPIER
- specific care given to solve problem from planning

A

Intervention

18
Q

SOAPIER
- response of patient
- answers question if goal was met
- primarily reassessment of data

A

Evaluation

19
Q

SOAPIER
- plan and modification suggested by evaluation

A

Revision