FUNDA LAB DOCU (2) Flashcards
is an essential tools for recording patient information accurately and comprehensively. These systems vary from traditional handwritten charts to sophisticated electronic health record (EHR) platforms.
documentation
a ____ also referred to as a chart or client record, serves as a for,al, legal document offering evidence of a client’s care, whether in written or computer based format
record
the act of recording information in a client record is known as _______ reflecting the standardized approach to documentation in healthcare settings
charting, documenting, recording
is anything written or printed that is relied on as a record of proof for authorized persons. _____ and reporting in nursing are needed for continuity of cars it is also a legal requirement showing the nursing care performed or not performed by a nurse
documentation
Through documentation and reporting, nurses facilitate seamless communication among healthcare professionals, ensuring the continuity of care and promoting patient safety.
communication
Through documentation and reporting, nurses facilitate seamless communication among healthcare professionals, ensuring the continuity of care and promoting patient safety.
planning client care
accurate documentation enables health agencies to assess compliance with regulatory standards, identify areas for improvement, and ensure the provision of high quality care
auditing health agencies
Documented data serves as valuable resources for ______ endeavors, contributing to evidence-based practice and advancements in nursing knowledge and patient care.
research
Documentation and reporting provide valuable learning materials for nursing students and healthcare professionals, offering real-life case studies and examples to enhance understanding and skill development.
education
thorough documentation supports ____ processes by accurately reflecting the care provided to patients, ensuring proper billing and €___ for healthcare services
reimbursement
Documentation serves as legal evidence of the care provided, protecting both patients and healthcare providers in case of litigation or disputes.
legal documentation
Aggregated data from documentation and reporting systems allow for the analysis of healthcare trends, outcomes, and performance metrics, facilitating continuous quality improvement initiatives and informed decision-making.
healthcare analysis
SOAPIER MEANING
subjective,objective ,assessment,plan,interventions,evaluation,revision
4 data organizations by patient prob
data base, problem list, plan of care, progress notes
for each identified problem, initial plans are developed and documented. these plans are divided into three categories: diagnostic, therapeutic, patient educ
plan of care
A complete history and physical examination, along with initial lab results and diagnostic tests, provide a baseline of patient information.
database
Derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved.
problem list
Using the SOAP (Subjective, Objective, Assessment, Plan) format, _______ detail ongoing care and updates for each problem. This format ensures consistency and thoroughness in documenting patient care.
progress notes
this format provide structured and systematic approaches to documenting patient care. by following these formats, healthcare providers can ensure thorough and consistent documentation facilitating effective comm, continuity of care and informed decision making
soap,soapie,soapier
what is pomr
problem oriented medical record
This section includes information provided by the patient about their symptoms, feelings, and perceptions. It often includes the patient’s chief complaint, history of present illness, and any other (ex: the patient reports sharp chest pain)
subjective data
it provides healthcare providers interpretation and analysis of the subjective and objective data. includes a diagnosis or a list of potential diagnoses ex: the patient is experiencing symptoms indicative of acute myocardial infarction
assessment
This section outlines the proposed plan of action to address the patient’s problems. It includes diagnostic tests, treatments, interventions, patient education, and follow-up plans. (ex: administer aspirin)
plan
This section details the specific actions and treatments carried out to address the patient’s problems. It includes medications administered, procedures performed, and other therapeutic interventions.
Example: “Administered 325 mg of aspirin and 0.4 mg of nitroglycerin sublingually. Initiated intravenous access and started a heparin drip.”
interventions
This section details the specific actions and treatments carried out to address the patient’s problems. It includes medications administered, procedures performed, and other therapeutic interventions.
Example: “Administered 325 mg of aspirin and 0.4 mg of nitroglycerin sublingually. Initiated intravenous access and started a heparin drip.”
interventions
this section documents the patient’s response to the interventions. It assesses the effectiveness of the treatments and any changes in the patient’s condition.
•Example: “The patient’s chest pain decreased from 8/10 to 3/10, and repeat ECG shows reduced ST-segment elevation.”
evaluation
