Concepts Ch. 16- documenting

ISBARR reprt to PCP stands for

-identify/intro(name, title unit) -situation(I'm call about pt. name and room #) -background (state admission date and diagnosis, brief synopsis of treatment, most recent vitals) -assessment(give your conclusions of sit. and state how severe prob is -recommendation(your solutions and what you think would be helpful) -read back (restate any orders, clarify, ask under what circumstances to call back)

explain SOAP

-method of charting narrative progress notes; -organizes data acc. to Subjective, Objective, Assessment(assign nursing diagnosis) and Plan

graphic sheet

A graphic sheet is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

nurse shift report

A nurse's shift report is given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing patient care.

telemedicine report's benefits

A telemedicine report can link healthcare professionals immediately and enable nurses to receive and give critical information about patients in a timely fashion.

narrative charting

Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress.

PIE charting method

PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified).

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar?

Quality improvement, research, decision analysis, and financial reimbursement are all uses for documentation.

source-oriented method

Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically.

consultation, referral, conferring, client education examples

The nurse involving social services in client care best demonstrates a consultation. Sending a client to an orthopedic clinic would best demonstrate a referral. Discussing client care with another nurse best demonstrates conferring. Informing the client about a weight loss program is client education.

problem-oriented method

The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems.

verbal orders must

be read back and verified

explain focus charting

focuses on patients concerns instead of a problem list

focus charting

follows a DAR model

instead of using a trailing zero

leave it off bc decimal point can be missed

instead of cc write

mL

instead of using U or IU use

unit and international unit

when using numbers below zero

use a leading zero

rules for > and <

write out greater than and less than

transfer report

A transfer report is a summary of a patient's condition and care when transferring patients from one unit or institution to another.

acuity charting forms

Acuity charting forms allow nurses to rank patients as high to low acuity in relation to the patient's condition and need for nursing assistance or intervention.

focus charting method

Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

instead of using Q.D. and Q.O.D. use:

daily and every other day

flow sheet

graphic record of abbreviated aspects of the patient's condition

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

graphic sheet

SOAP charting

in SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. S = subjective data; O = objective data; A = analysis of the data; P = plan for care.

instead of μg

mcg or micrograms

instead of using MS and MSO4 and MgSO4 use

morphine or magnesium sulfate

do we abbreviate medications?

no

Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications:

the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?

the lower extremities