Documentation Flashcards
Parts of patient health history
Past/present illness, exams, tests, treatments, outcomes
Source oriented system
variety of sections, data scattered, used in hospitals and long term care
Problem oriented system
Centered around client problem. Data base, problem list, plan of care, progress notes. Promotes collaboration.
Charting by exception
Only out of the norm/exceptions recorded
Electronic Health Record system(EHR)
combines record styles, can crash
Paper records
slow, high error, HCP comfy, inexpensive. line through errors and open space, sign everything.
Documentation formats
PIE, SOAP(IE(R)), narrative
PIE documentation
P - problem
I - intervention
E - evaluation
SOAP(IE(R)) documentation
S - subject
O - objective
A - assessment
P - plan
I - intervention
E - evaluation
R - revision
narrative documentation
problem/source oriented, story layout
Types of forms used in nursing
Admission, discharge, flowsheets/graphic records, med admin records(MAR), nursing assessment, Kardex, integrated plan of care, occurrence reports, handoff reports
Admission forms
establish baseline, vitals, allergies, med list
Discharge forms
start at admission, last entry made before pt leaves
Flowsheets/graphic records
recurring care records
Medication administration forms (MAR)
med admin and related vitals/measurements, refusals, omissions
