Observing, Reporting & Recording + Documentation Flashcards
signs observed using your four sense of sight, hearing, smell, and touch
objective data
subjective data
what a client says to you in their own words (i.e. symptoms, comments, complaints)
How would Eva Hearn, Seneca College PSW Student sign their name when documenting?
Eva Hearn, SCPSW Student or E. Hearn, SCPSW Student
the steps in the nursing process/care planning process
- Assessment
- Nursing diagnosis
- Planning
- Implementation
- Evaluation
medical diagnosis
made by physician, identifies a disease or condition
nursing diagnosis
statement describing a health problem that is treated by nursing measures (ex: social isolation, spiritual distress)
what planning involves in the nursing process
establishing priorities and goals, developing measures or actions to help client meet the goals
recording vs reporting
recording = written reporting = verbal
chart/record
permanent and legal document required to record a client’s condition, signs and symptoms of any illness, the care and treatment given to client, and client’s response to care
how long is a client chart/record kept in Ontario
minimum of 5 years
care plan
contain goals and interventions based on assessment
progress notes/narrative notes
information about client and their care in a chronological order
SOAP charting
subjective data
objective data
assessment analysis of data
plan of care
ADPIE charting or PIE charting
analysis diagnosis \+ problem intervention evaluation
Focus charting or DAR charting
data
analysis + action
response
