DOCUMENTING Flashcards
an informal oral consideration of a subject by two or more health care personnel to identify a problem
DISCUSSION
Is oral, written, or computer-based communication intended to convey information to others
REPORT
only a written/computer based
RECORD
recording is also called
charting or documenting
is the process of making an entry on a client record
RECORDING
clinical record is also called
chart/client record
It is a formal, legal document that provides evidence of a client’s care
CLINICAL RECORD
The nurse has a duty to maintain _____ of all patient information”
confidentiality
Access to the record is ____ to health professionals involved in giving care to the client
restricted
who is the rightful owner of the client’s record
The institution or agency
purpose of client records
Communication
Planning client care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis
the traditional client record each person or department makes notations in a separate section/s of the client’s record
SOURCE-ORIENTED RECORD
example of source oriented record
the admission dept. – Admission sheet
the physician – Doctor’s order sheet
A physician’s history sheet
Progress notes
the traditional part of the source-oriented record
Narrative Charting
It consists of written notes that include routine care,
normal findings, and
client problems.
Narrative Charting
meaning of POMR
PROBLEM-ORIENTED MEDICAL RECORD
who established POMR
Lawrence Weed
what record in which the data arranged according to the problems the client has rather than the source of the information
POMR
4 COMPONENTS OF POMR
Database
Problem List
Plan of Care
Progress Notes
FORMATS OF PROGRESS NOTES
SOAP, SOAPIE/SOAPIER ; PIE
meaning of SOAP
subjective
objective
analysis
planning
SOAPIE/SOAPIER means what
subjective
objective
analysis
planning
intervention
evaluation
revision
meaning of PIE
problem
intervention
evaluation
consists of all information known about the client when the client first enters the health Care agency
Database
problems are listed in the order in which they are identified, and the list is continually updated as new problems are identified and others are resolved
Problem List
the initial list of orders made with reference to the active problems.
Plan of Care
advantage sa pomr
encourage collaboration
alerts caregivers to clients needs; easier to track problems
disadvantages of pomr
caregivers ability to use charting format
takes constant vigilance to maintane an up to date list
inefficient (assessments & interventions are repeated)
is intended to make the client and client concerns and strengths the focus of care.
FOCUS CHARTING
recrding in focus charting consist of
date and time
focus
progress notes
which charting utilizes DAR
focus charting
meaning of DAR
data, action and response
a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.
CHARTING BY EXCEPTION
3 elements of charting by exception
flow sheets
standard of nursing care
bedside access to chart forms
like graphic record, fluid balance record, daily nursing assessment record, client teaching record, client discharge record and skin assessment record
Flow sheets
are being developed as a way to manage the huge volume of information required in contemporary health care
COMPUTERIZED DOCUMENTATION
emphasizes quality, cost-effective care delivered within an established length of stay
CASE MANAGEMENT
Uses a multidisciplinary
approach to planning
and documenting
client care, using
critical pathways.
CASE MANAGEMENT
DOCUMENTING NURSING ACTIVITIES:
- Admission Nursing Assessment
- Nursing Care Plans
- Kardexes
- Flow Sheets
- Progress Notes
also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit
Admission Nursing Assessment
2 TYPES OF NURSING CARE PLANS
traditional
standardized
a care plan that is written for each client. Mostly, it has 3 columns: nsg. diagnosis, expected outcomes, and nsg. interventions
traditional
care plan that was developed to save documentation time.
standardized
a widely used, concise method of organizing and recording data about a client ;consists of a series of cards kept in a portable index file or on a computer-generated forms.
Kardexes
made by nurses to provide information about the progress a client is making toward achieving desired outcomes.
Progress Notes
GENERAL GUIDELINES FOR RECORDING
Date and Time
Timing
Legibility
Permanence
Accepted Terminology
Correct Spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal prudence
purpose of reporting
to communicate specific information to a person or group of people
is given to all nurses on the next shift.
Its purpose is to provide continuity of care
Change-of-Shift Reports
reports done through telephone
Telephone Reports
orders made by physicians through telephone.
Transcribed onto the physician’s order sheet and should be counter signed within 24 hours by the physician who made the order
Telephone Orders
is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.
Care Plan Conference
are procedures in which two or more nurses visit selected clients at each client’s bedside.
Nursing Rounds
