Documenting Flashcards
define documentation
the written or typed legal record of all pertinent interactions with the patient - assessing, diagnosing, planning, implementing, and evaluating
what document is the nurse’s best defense if patient alleges negligence?
patient record
what is a source-oriented record?
healthcare group keeps data on its own separate form
what are progress notes?
notes written to inform caregivers of the progress a patient is making
what are narrative notes?
progress notes written by nurses that address routine care, normal findings, and patient problems.
Includes description of problem, related nurse intervention, patient responses, and needed revisions
what is POMR?
Problem-oriented medical record
-type of record used that is organized around a patient’s problems rather than sources of information
what is the SOAP format for?
used to organized data entries in the progress notes of the POMR
what are the variants of the SOAP format and what do they stand for?
Subjective data, Objective data, Assessment, Plan (SOAP)
“….”, Evaluation (SOAPE)
“….”, Intervention, Evaluation (SOAPIE)
“….”, Intervention, Evaluation, Response (SOAPIER)
what makes PIE charting unique?
it does not develop a separate plan of care
what is focus charting?
brings the focus of care back to the patient and the patient’s concerns
what is the narrative portion of the focus chart?
Data, Action, Response (DAR)
what is charting by exception (CBE)?
documenting only significant findings or “exceptions” to well-defined standards of practice
what are minimum data sets?
specific categories of information that will use uniform definitions to create a common language among multiple healthcare data users
what is “PHR”
personal health record- using the Web to manage healthcare
how the Kardex used?
the Kardex is recorded on a folded card and placed in a central Kardex file where it is easily assessible
