Chapter 5 Fundamentals of Nursing Lecture: Documentation
What are the methods of charting
Charting by Exception Focuse charting Kardex Narrative Charting Pie charting SOAPIER charting
Purpose of documentation
Communicate data to health care team Provide a permanent record Accountably for quality assurance Legal record
What is focus charting (Dar)
Data- objective and subjective Action- Intervention Responds- Patient's responds to interventions, evaluation phase of nursing process
What is the Health Portability Act and Accountably Act
Maintains the confidentiality of patient data Only the health care providers directly involved in patient care have access to the record. Patient must consent in writing to send medical records to another physician
What does the quality assurance committee do?
Monitor the quality of care delivered Helps detect problems or areas of weakness Statistics serve as defining factors of a facility's reputation
Describe continuity of care
Nursing responsibility to document 24/7 Patient care must be delivered and evaluated continuously and systematically
What is Pie charting
P-Problem I-intervention E-Evaulation
Permanent record of care
Patient's condition Diagnosis Results of diagnostic test and procedures All medical and interdisciplinary care Patient outcome Source of medical history for reference
What should a nurse document
Patients current condition and changes Care delivered and it effectiveness Future care
When should you document
Right away
What is the SOAPIER method of charting
S-Subjective O-objective A-Assessment P-Plan I-Intervention E-Evaluation R-Revision
What is narrative charting
To tell a story of experience
