Charting 2 Flashcards
narrative method of charting
the traditional method
problem-oriented medical record (POMR)
database, problem limit, nursing care plan, progress note
SOAP
subjective, objective, assessment, plan
SOAPIE
subjective, objective, assessment, plan, intervention, evaluation
PIE
problem, intervention, evaluation
Focus Charting (DAR)
Data, Action, Response
source records
a separate section for each discipline (what the hard chart is now)
charting by exception (CBE)
focuses on documenting deviations (when compromised chart)
case management plan and critical pathways
incorporates a multidisciplinary approach to care
WNL
everything by case definition was met
common record keeping forms
admission nursing home history form, flow sheets and graphic records, client care summary or Kardex (SBAR), acuity records, standardized care plans, discharge summary form
medicare has specific guidelines for
establishing eligibility for home care (home care documentation)
documentation is the quality control and justification for reimbursement from
medicare, medicaid, or private insurance (home care documentation)
nurses need to document all their services for
payment OASIS (home care documentation)
governmental agencies are instrumental in determining the
standards and policies for documentation (long-term health care documentation)
the Omnibus Budget Reconciliation Act of 1987
includes Medicare and Medicaid legislation for long-term health care documentation
the department of health in states governs the
frequency of written nursing records (long-term health care documentation)
never talk about what type of report in the chart
incident reports
what do you always have to read back
verbal or telephone orders
how to document verbal/telephone order
Doctor Name Rachael Garland TORB (doctor has to sign within 24 hours)
reporting
change of shift, telephone reports, verbal/telephone orders, transfer reports, incident reports
software programs allow nurses to
enter assessment data
computers generate
nursing care plans and document care
HIPPA
started in 2003, app to give patient greater control over their own records
