Basic Nursing Chap 5 & 20
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