Documentation Flashcards
Documentation
written evidence of (1) interactions between and among health professionals, clients, their families and health care organizations (2) administration of tests, procedures, treatments, and client education, and (3) results or client’s response to these diagnostic tests and interventions
Charting by Exception
charting methods that requires the nurse to document only deviations from pre-established norms
Critical Pathway
abbreviated summary of key elements from teh case management plan
DRG
diagnosis related group- standardized method of classifying medical diagnoses
Flow Sheets
documentation method using vertical or horozontal columns for recording dates and times to show assessment and interventions or client teaching use of special equipment and IV therapy; easy to track changes in client’s condition
Focus Charting
DAR note- documentation method using a columnar format to chart data, action, and response
Incident report
documentation of an unusual occurrance or an accident in delivery of client care
Kardex
summary worksheet reference of basic client care information
Narrative Charting
story format of documentation that describes teh client’s status, interventions and treatments, and the response to the treatments
POMR
problem oriented medical record; documentation focused on client’s problem wiht a structured, logical format to narrative charting (SOAP)
SOAPIER charting
documentation method using subjective data, objective dta, assessment, plan, interventions, evaluation, and revision
Variance
variations, goals not met or interventions not performed according to the timeframe
SOAP
subjective, objective, assessment, plan
PIE
Problem, Intervention, Exvaluation
