Documentation Flashcards
It serves as a permanent record of patient information and care.
Documentation
They are responsible for accurate, complete, and timely documentation and reporting.
Nurses
Documentation and reporting of patient’s condition require adherence to the:
highest standards of confidentiality
Clear, accurate, up-to date patient documentation; provides flow of information between providers of care.
Patient Medical Record
Compilation of health-related data.
Patient Medical Record
Purposes of medical record:
- Communication
- Assessment
- Care planning
- Legal document
- Quality assurance
- Reimbursement
- Research
A software program that allow nurses to enter assessment data quickly, usually by checking boxes and adding text when appropriate.
Electronic Health Records (EHR)
It interfaces medication orders with pharmacy dispensing and allow direct computer charting of medication administration.
Electronic Medication Administration Record (eMAR)
Portable files; not part of the patient record or chart.
KARDEX or Patient Care Summary
Tablets that allow nurses to document routine assessment and procedures.
Flow sheets
Examples of flow sheet:
- IV flow sheet
- Insulin sheet
Only significant findings (exceptions) are documented.
Charting by Exception
Advantages of charting by exception:
- Requires less time
- Guidelines about expected outcomes and normal assessment parameters are clear.
- Changes in patient status can readily be detected.
Disadvantages of charting by exception:
- Takes time to develop and maintain standards and flow sheet
- Legal challenges
Reflect a specific problem being addressed or the care provided over a specific period; varied format depending on the agency.
Nursing Progress Notes
Forms of Nursing Progress Notes:
- Narrative notes
- SOAP notes
- PIE notes
- FDAR notes
Includes date and time of entry, identification of the role of the person writing the note, specific activities accomplished.
Narrative notes
Where are narrative notes commonly found?
In an inpatient setting
Advantages of Narrative notes:
- Easy to learn
- Easy to adjust length as needed
- Can explain in detail
Disadvantages of Narrative notes:
- Time consuming
- Irrelevant information often included
- Possibly unfocused and unorganized
Relates only to one health problem.
SOAP notes (Subjective, Objective,
Assessment, Plan)
Advantages of SOAP notes:
- All charting focuses on identified problem
- Interdisciplinary (all members can chart on the same progress notes)
- Easy to track progress
Represents a diagnosis, an impression, or a condition change.
Assessment
Deals with nursing intervention specifically related to the identified problem.
Plan
Incorporating the plan of care into progress notes; entered for each nursing diagnosis during every shift.
PIE notes (Problem, Intervention, Evaluation notes)
Entry can be made on a significant event, possible growth or learning that occurs during the teaching session.
FDAR notes (Focus, Data, Action, Response notes)
