DOCUMENTATION Flashcards
an 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
oral, written, or computer based communication intended to convey information to others
report
it is a formal, legal document that provides evidence of a client’s care and can be written or computer based
record/chart/client record
the process of making an entry on a client record is called
reporting/charting/documenting
the client’s record is protected legally ; it is a _ record
private
__ is the rightful owner of the client’s record
institution or agency
the student or health professional must protect the client’s privacy by not using a __ or __ that would identify the client
name or any statement
the traditional client record is a _ record ; notations in a separate section or sections of the client’s chart
source-oriented record
traditional part of the source-oriented record ; consists of written notes that include routine care, normal findings, and client problems ; no right or wrong order to the information, just chronological
narrative charting
who established the problem oriented medical record
lawrence weed
record that encourages collaboration and problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem
POMR
consists of all information known about the client when the client first enter the health care agency
database
derived from database ; kept at the front of the chart and serves as index to the numbered entries in the progress notes
problem list
is a chart entry made by all health professionals involved in a client’s care
progress note
it is where the statement of the problem should be ; description of the client’s condition and level of progress
assessment
it is primarily the reassessment data
evaluation
intended to make the client and client concerns and strengths focus of care
focus charting
meaning of FDAR
focus
data
action
response
in fdar, it reflects the planning and implementation ; immediate and future nursing action ; changes on the plan of care
action
in fdar, it reflects the evaluation phase of the nursing process
response
used to manage the huge volume of information required in contemporary health care
EHR
it emphasizes quality, cost-effective care delivered within an established length of stay ; uses a multidisciplinary approach to planing and documenting
case management
a goal that is not met is called a__ ; deviation from what was planned on the critical pathway
variance
it should describe the client’s ongoing status and reflect the full range of the nursing process
client record
it is completed when the client is admitted to the nursing unit
initial database/nursing history/assessment
two types of nursing care plans
traditional and standardized
developed to save documentation time
standardized
widely used, concise method ; makes information quickly accessible to all health professionals
kardex
employs a stuctured, logical format ; SOAP, SOAPIE, SOPIER
problem oriented medical record
use of a column format to chart data, action and response
focus charting
communication tool that provides a method of clearly communicating the pertinent information
ISBARR
these reports happen any time one health care provider transfers care of a patient to another healthcare provider ; to provide better continuity
handoff reports
two types of handoff reports
change of shift
transfer report
is given to all nurses on to the next shift ; up to date information about patient’s condition
change of shift report
given whenever the patient is transferred to other health care unit ; nursing to nursing
transfer report
health professionals frequently report about a client by telephone
telephone reports
occurs when a healthcare provider gives an order over the phone to a registered nurse
telephone order
involves the healthcare provider giving orders to a nurse while they are standing near each other
verbal order
they usually occur at night or during emergencies and frequently causes medical errors
telephone order
verbal order
any event that is not consistent with the routine operation of a healthcare unit or routine care of a patient
incident or occurrence reports
