Types of Charting Flashcards
1
Q
SOAP
A
Subjective data - what the patient says
Objective data - what you see
Assessment - interpretation or conclusion
Plan - what the care plan will do to resolve the issue identified by your assessment
- A lot of doctors use SOAP charting
2
Q
SOAPIER
A
same as SOAP except IER
Intervention - what has been done
Evaluation - patient’s response
Revision - reflects care plan modification
3
Q
PIE
A
Problem - nursing Dx
Intervention
Evaluation
- Generally looking at your nursing care plan at the same time to identify nursing diagnosis
- ex: P#1 ineffective airway clearance
- popular form of charting
- built right off nursing process
4
Q
Kardex
A
not always utilized
- summary of everything
- only meant to be used as a guide
- it’s not legal document
5
Q
Graphic Record
A
- VS, I/O, basic care - bath
- legal document
6
Q
MAR
A
Medication Administration Record
- nurse has to sign
- legal
7
Q
Skin Assessment
A
different forms
done every 2 hours
8
Q
Fluid Balance Record
A
I/O’s
