RLE Flashcards
Describes the patient’s charting and focuses
on documenting the patient’s current status,
progress toward goals, and response to
interventions
● It is a systematic approach to
documentation, using nursing terminology to
describe an individual’s health status and
nursing action.
Focus charting
FDAR -
Focus, data, action, response
Subjective and Objective information
supporting the stated focus;
● Description of observations during the time
of the event.
Data
Nursing Intervention performed, planned to
be done, guidelines, and protocol to be
initiated.
Action
Effective interventions are based on the
____ of the patient to the care.
● It is indicative of reaching the goal of the
Plan of Action and is progressing towards
achievements
Response
6am-2pm (morning shift) colored pen:
Black ink
2pm-6pm (afternoon shift) - colored pen:
Blue ink
6pm-6am (night shift) -colored pen:
Red ink
- Writing down or copying from one place to
another
Transcribing doctor’s order
Types of doctor’s order:
Verbal
Written
Telephone
Electronic (email, viber, telegram, soc med apps)
Make sure that the five{5} rights are there in
the doctor’s order
Right name of the patient
Right name of the drug
Right dosage
Right time/frequency
Right route
● Is a desktop file system that gives a brief
overview of each patient and is updated
every shift. It is a reference for nurses that
is separate from the patient’s chart. And is
usually kept at the nursing station for quick
assessment.
communication tool used to
convey the client’s current orders as well as
upcoming tests or surgery, diet, etc. quickly
and briefly.
● Nurses use it to organize the care and to
manage time and multiple priorities.
May be in paper or electronic format
Kardex
● Is a method of grouping patients according
to the amount of complexity of their nursing
requirements, and the nursing time and
skills they require.
Patient care classification
Means of categorizing present patients on
the basis of certain care needs that can be
clinically observed by the nurse
Patient classification system
● Is a process of assigning competent people
to fulfill the roles designated for the
organizational structures
● Is the process of finding the right number of
personnel to meet the needs of the patient
in the practice setting.
Staffing/Nurse staffing
