Basic Nursing Chap 5 & 20

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what you can see, smell, feel, hear, and ovserve

objective data

what is the purpose of a permanent record of care

source of medical history for reference when the patient requires health care in the future

Documentation

the act of charting or making written notation of all the thins that are pertinent to each patient for whom you provide care. Perment recording of information properly identified as to time, place, circustance, and attribution

What is the 1st purpose of documentation

to communicate pertinent data that all health care team members need in order to provide continuity of care

What is the 2nd purpose of documentation

to provide a permanent record of medical diagnoses, nursing diagnoses, the plan of care, the care provided, and the patient's response to that care

what is the last purpose of documentation

to serve as a legal record for both the patient and the health care provider

What is the 3rd purpose of documentation

to serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes

when contacting a physician what information is given

concise statement of the problem and why you are calling, vital signs, laboratory results, diagnostic tests, etc

what does Focus Charting (DAR) mean

Data- objective or subjective Action- interventations Response- patient's response to interventions, evaluation phase of nursing process

What is continuity of care

Medical Uninterrupted health care for a condition from the time of first contact-eg, to the point of resolution or long-term maintenance. The patient's current condition and changes, care dlivered and its effectiveness, and future care

What is PIE charting

Problems of nursing diagnosis Interventions or actions taken Evaluation of the outcome of nursing intervention

what does SBAR guide to communication stand for

S: situation what is happening at that time B: backgroun explain circumstances leading to the situation A: assessment what do you think the problem is R: recommendation what would you do to correct the problem

what are the methods of charting

SOAPIER, PIE, Focus, Charting by exception, and narrative

what does SOAPIER stand for

Subjective data Objective data Assessment data plan Intervention Evaluation Revision

Who sets the standards by which quality of health care is measured

The Joint Commission

What Items to include in a Shift report

basic patient data, scheduled procedures, pertinent diagnostic results, abnormal assessment findings, interdisciplinary terapies ordered, vaious ordered treatments

What are some guide lines for documentation

black or blue ink, sign each entry, put date and time with each entry, follow chronological order, entries in a timely manner, be succent, use punctuation, approved abbreviations, be accurate, no blank lines


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