Documentation Flashcards
1
Q
Standards applicable to all nurses
A
Clients status including signs and symptoms
Nursing care rendered
Administration of medications and treatments
Clients responses
Contact with other health care team members concerning significant events regarding clients status
2
Q
Examples of treatment
A
Turning them in bed so they don’t get ulcers
Breathing treatment
Ambulating
Occupation
Social services
Dietary
Chaplan or anyone on the team that helped you
Their response to what you helped them with (if the patient got better or worst)
3
Q
DAR
A
Data action responsesHow did patient respond?
4
Q
Soap/soapier/ soapie
A
Subjective objective assessment plan intervention evaluation revision
5
Q
P I e
A
Problem intervention evaluation nursing focused
