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Involves recording the interventions carried out to meet the patient's needs.
Done in a proper way, it reflect the nursing process.
Necessary to prove that nursing work was done.
Nursing documentation can be accepted in both verbal and written form
Sometimes used by government agencies to evaluate patient care
It is a permanent record for accountability
It is a legal record of care
They are perfect sources for business and marketing
Can be used for research, teaching and data collection
Minimum data sheet
Diagnoses related groups
Patient expense documentation
Use direct quotes for objective assessments
If a charting error is made, draw one line through the faulty information
Chart only your own care even when someone else calls you for a late entry.
Chart after care is provided, as soon as possible, and as often as needed
Sign each block of charting with full legal initials and title
Never erase entries or use correction fluid. Never right with a pencil.
Do not record "physician made error".
Be certain that entry is factual even when opinions are used
While logged into the computer, do not leave terminal unattended even during an emergency.
Not charting correct time when events occurred
Failing to record verbal orders or failing to have them signed
Documentation only in hand written format even when EMR is mandated
Charting actions in advance to save time
Documenting incorrect data
Charting interventions in advance to save time
Documenting incorrect data
Not charting the correct time when events took place
Deleting incorrect entries and crossing them out with a horizontal line.
Not recording verbal orders or not having them signed.
Problem-oriented medical record
Admission sheet and physician's orders
Progress notes and nurse's admission information
History and Physical Examination Data
Medical Administration Record
Care plan and nurse's notes
Problem Oriented Medical Record
Traditional uses an abbreviated story form. POMR uses an outline form
Traditional uses SOAPE charting. Problems oriented medical record uses narrative charting
Traditional uses blocks. POMR uses sections.
Traditional focuses on interventions. POMR focuses on interventions.
Physical examination and diagnostic tests
It is not mentioned in this kind of documentation
Included in the notations under PLANNING
Included under assessment
It belongs to another format
REVISIONS belong to another format of documentation
REVISIONS are not part of this documentation
REVISIONS are noted in the EVALUATION section
REGISIONS are noted in the ASSESSMENT section
Uses the nursing process and the more positive concept of patient needs
Focus is sometimes a current patient concern or behavior.
Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient's therapy.
Focus can be a medical diagnosis
Data, action, response and evaluation, education and patient teaching
Data is both subjective and objective
Action combines planning and implementation
You need to use all the DARE steps each time you make notes on a particular focus
Response is the same as evaluation and effectiveness
Some facilities include education or patient teaching
PIE is from a nursing process. SOAPE is from a medical model
PIE is from a medical model. SOAPE is from a nursing process
PIE and SOAPE are both used for charting by exception
PIE and SOAPE both emerge from the nursing process
Additional treatments done or planned treatments withheld
Standing orders and physical history
Changes in patient condition
It needs to be a part of the SOAPE documentation
It needs to be explained to the next shift
It is no longer covered by daily documentation
It needs to be transferred to a permanent record
Kardex or Rand
Nursing Care Plan
24-hour patient care and acuity charting
Each time you give a medication
Each time a bath is given
Each time a decubitus ulcer changes in appearance
Each time you assess vital signs
Kardex or Rand System
Nursing Care plan
Nursing Care Plan
Common illness index
Health intervention reference
Standardized nursing care plans
Plans written in nursing notes
Kardex or Rand
Do not admit liability or give unnecessary details
List date, time and care given to the patient and the name of the Physician notified.
Personal assessment and judgment of incident
When charting the incident in the patient's nursing notes, do not mention the incident report.
Helps eliminate unnecessary record keeping forms
Enhances efficiency because flow sheets and checklists are often used.
Accommodates a 24-hour period
Necessary to maintain a good nursing care plan
Charting by exception
Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.
Clinical pathways that delve with cases occur in high volume and are predictable.
The clinical pathway replaces other nursing forms such as the nursing care plans
Charting by exception is usually the method used for clinical pathways
The exact contents and format of these clinical pathways are the same among different institutions.
It provides a narrower scope of people for a wider majority of services.
Requires a whole health care team to work closely
Does not demand meticulous and thorough documentation
Duplication of documentation is difficult to avoid
I am required to give you a request form so that I can prove you wanted your records and not just anyone else.
Your original health care record belongs to the Physician.
One moment, let me make a copy of it immediately. How many do you want?
I am so sorry but you really do not have a right to look at your own records.
County hospitals such as Stroger's Hospital
University clinics such as PCCTI Nursing lab
Federal Health Care Agencies such as VA hospitals
Municipal Health Care Centers such as Oakbrook Health Center
Log into the system with a secure password
Log into the system with a common password
Log into the system with a borrowed password
Log into the system with a friend's password
Documentation by the nurse
Appropriate physician progress notes
Minimum data sheets
Read the medical history for your own education.
Turn off the computer as soon as possible
Print the document to serve as future reference
Call your clinical instructor and ask what to do