Unit VI Documentation : reporting and recording

student signature

legible with initials after it

charting by exception

Documentation system in which only abnormal or significant findings or exception to norms are recorded

SOAP, SOAPIE, SOAPIER, DAR, PIE

S- subjective data O- objective data A- assessment P- the plan I- interventions E- evaluation R- revision

APIE, PIE

assessment, plan, interventions, evaluation) plan, interventions, evaluation

quality assessment

assures the proper assessments, diagnosing, planning, implementing, and evaluating for the patient

electronic medical records

computer based record of clients record

narrative entries

consists of written notes that include routine care, normal findings, and client problems.

DAR

data, action,planning

ambiguous terms

having more than one meaning

focused charting

intended to make the client and client concerns and strength the focus of care

reporting

making an entry on a client record, data arranged accoring to the problems the client has rather than the source of the info

MAR

medication administration records

The EMR (electronic medical record)

navigating, recoring assessment data, collecting data

components of nursing Kardex

pertinent info about client, such as name, room number, age, admission date, primary care provider's name, diagnosis, and type of surgery. allergies. list of meds with date of order and the times of administration for each. list of all intervenous fluids, w dates of infusion. all daily treatments and procedures, such as irrigations, dressing changes, postural drainage, or measurement of vital signs. list of diagnostic procedures ordered, such as x-ray or lab tests, specific data on how clients physical needs are to be met, such as type of diet, assistance needed w feeding, elimination devices, activity, hygienic needs, and safety precautions. a problem list, stated goals, and list of nursing approaches to meet the goals and relieve the problems.

common abbreviations

pg. 264 avoid normal, abnormal, good, fair, poor and WNL

POMR

problem oriented medical record

quality assurance

promoting excellence in health care provided to clients

situational and structural reporting

situation- state your name, unit, and client name. briefly state the problem structural reporting- change of shift reports, walking rounds, patient care conferences

recording

the process of making an entry on a client record

characteristics of effective reporting

up to date info, interactive communication allowing for questions between the giver and the receiver of client info, method for verifying the info, minimal interruptions, opportunity for receiver of info to review relevant client data / focused, orderly precise, concise, and comprehensive

flow sheet

uses specific assessment criteria in a particular format, such as human needs or functional health patterns

Kardex

widely used concise method of organizing and recording data about the client making info quickly accessible

narrative notes

written notes including routine care, normal findings and client problems