Fundamentals of Nursing Unit 3: Chapter 7, 8, 9 & 10

Advantages of Focus Charting?

-Compatible with the use of the nursing process -Shortens charting time: many flow sheets, checklists

Disadvantages of computer assisted charting?

-Expensive to purchase and update -Problems with "downtime" interfere in charting and receiving information -Increase charting time if not enough terminals -May not be user friendly. May be difficult to quickly find information needed to make care decisions

What is source oriented/narrative charting?

1. Charting organized by "source" or author of the charting entry 2.there are different forms for physicians, nurses, dietitians, etc. to document their findings and plan the patient's care Documentation of patient care needs to be in chronological order & follows a body systems format

Computer Assisted Charting

Charting in which data are input via the computer

4 factors that effect communication

Cultural differences Past experiences Emotions and mood Attitude of the individual

How we perceive what is communicated to us depends on:

Cultural values Level of education Familiarity with the topic Occupation Previous life experiences

3 components of Focus Charting?

D: data, A: action, R: response (DAR) D: data, A: action, E: evaluation (DAE)

What is Focus Charting?

Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event

Case Management System Charting

Documentation that tracks variances from the clinical pathway

What is Problem Oriented Medical Charting POMR

Focuses on patient status rather than on medical or nursing care Five basic parts: database, problem list, plan, progress notes, and discharge summary

Advantages of Source oriented charting?

Includes all steps of the nursing process **Data is given in a chronological order** Indicates the patient's baseline every shift

What is PIE charting?

PIE = problem, intervention and evaluation Problem - state the issue/problem that patient is stating or dealing with Intervention - describe how problem was addressed - what was done to fix the problem? Evaluation - what was the outcome of the intervention

Purpose of Documentation

Provides patient medical history, Is a guide for reimbursement of costs of care May serve as evidence of care in a court of law Shows the use of the nursing process Provides data for quality assurance studies Is a legal record that can be used as evidence of treatment Contains observations by the nurse Shows progress toward expected outcomes

Advantages of Computer Assisted Charting?

Quick communication between departments (plus simultaneous access) Information is more accurate, more legible Cost effective in time dollars Reimbursement is initiated at a quicker pace and the charge entry is more accurate to promote full moneys owed

Disadvantages of Source Oriented Charting?

Repetitive, disorganized, and takes too long to find information and can lead to decrease communication between health care providers

What is Charting by Exception

Shorthand method of documenting findings by only charting abnormal findings.

Advantages of POMR

Utilizes the problem solving approach and reinforces the nursing process Conducive to continuity of care and communications, all info in one place **Encourages constant evaluation and revision of the plan of care - ALWAYS CURRENT ** Is patient focused and comprehensive Easy audit of pt record and staff performance

Disadvantages of Focus Charting?

database is not sufficient, patient problems may be missed, does not adhere to charting w/ the focus on nursing diagnoses and expected outcomes.

Disadvantages of POMR

loss of chronological charting (each problem charted separately) Increased number of flow sheets Addresses one problem at a time not interrelated to the whole picture Difficult to track trends in patient progress