NCM 119 RLE Flashcards
Describes the patient’s charting and focuses on documenting the patient’s current status, progress towards goals and response to interventions?
Focus Charting
it is a systematic approach to documentation, using nursing terminology to describe individual’s health status and nursing action
Focus charting
Key word or assessment category on a nursing diagnosis
Focus
It notes and record unexpected events during the course of Nursing Management
Focus notes
Subjective or objective information supporting the stated focus
Data
Description of observations during the time of the event
Data
Nursing intervention performed, planned to be done and guidelines, protocol to be initiated
Action
Effective interventions are based from the response of the patient to the care.
Response
FDAR should be _____ oriented, not ______ Oriented
Patient, nurse
Used in comprehensive assessment of the patient
Inspection, Palpation, Percussion, Auscultation
Fluid taken in the body
Intake
What metric should nurse record intake and output
mL
1 tsp = ____ mL
5
1 tbsp = ___ mL
15
1 oz = ____ mL
30
