Week 10 Flashcards
Data forms or assessment forms
Details
Assist with identifying problem areas
Home assessment forms
Changes that need to be made to clients home
Care plan
Contains goals and interventions
Other flow sheet
Record measurement and observations
Summary report
Monthly or every so often summary of clients condition/services used
Progress report (RN) or narrative note (PSW)
Care that we provided
Graphic sheets
Record measurement and observations
ADL checklist and flow sheets
Sometimes called risk sheets
Task sheets
Record provided care and services
Incident report
Written account made after accident, error or unexpected event
Kardex
One - two page document that is updated frequently
Agency polices about medical records address:
Who records, when records
Terminology, abbreviation, correcting errors
What to do for an error
Cross a line through it,
Write mistake and why,
Date, name, signature
SOAP
Subjective data
Objective data
Assessment
Plan
PIE
Problem
Intervention
Evaluation
ADPIE
Analysis
Diagnosis
Problem
Intervention
Evaluation
DAR charting
Data
Analysis and action
Response
Transfer of accountability (TOA)
Handover of information between shifts
Sometimes recorded, written, or vocal
Formal process
Objective, appropriate, and concise
Writte up patient observations
TOA tips
Be organized
Stay focus
Stay relevant
Communication clearly
Be patient- centred
Allow time
ISBAR
Identify
Situation
Background
Assessment
Recommendation
