Professional Communication Documentation And Informatics Flashcards
1
Q
Documentation
A
Anything written or printed on which you rely as record or proof of patient actions and activities
2
Q
Guidelines for quality documentation and reporting
A
Factual Accurate Complete Current Organized -signature
3
Q
SOAP
A
Subjective data
Objective data
Assessment
Plan
4
Q
SOAP IE
A
Subjective data Objective data Assessment Plan Intervention Evaluation
5
Q
PIE
A
Problem
Intervention
Evaluation
6
Q
DAR
A
Data(both objective and subjective)
Action or nursing intervention
Response for the patient
7
Q
Legal documentation
A
Accurate documentation is one of the best defenses for legal claims associated with nursing care
8
Q
SBAR
A
Situation
Background
Assessment
Recommendation
