Finals 2 Flashcards
(25 cards)
Clear and accurate _____ is vital as a communication tool for all members of the healthcare team.
Documentation
It facilitates the flow of information between all member of the healthcare team ensuring that the most up to date patient information is available to assist with continuity of care and appropriate decision making regarding an individuals care and treatment
Documentation
Serves as evidence and a formal legal document if a member of a healthcare team is called to explain persons care within a legal setting
Patient documentation
What are the 5 C’s of documentation
-clarity
-conciseness
-completeness
-confidentiality
-chronological order
What does SOAPIE means
Subjective information
Objective information
Assessment
Plan
Implementation
Evaluation
Documentation should include what the patient says or information that only the patient can provide personally.
Subjective information
Record what nurse observes, hears, sees and feels during the patient assessment.
Objective information
After subjective and objective information, this data is collected, the nurse should make an initial analysis of the patient condition and identify any appropriate nursing diagnosis.
Assessment
Once an initial nursing diagnosis has been identified, the nurse must create a ____ of action
Plan
After the plan of action has been decided, the actions or intervention should be put into motion.
Implementation
The outcomes of the interventions need to be _____.
Evaluated
What does FDAR means?
Focus
Data
Action
Response
A method that is intended to make the client and clients concerns and strands focus of care.
FDAR
What is in the first column indicates when the documentation entry was made.
Date and time
It is in the second column that is the central focus of patient care.
Focus
The progress notes are organized into
Data
Action
Response
The _____ category resembles the assessment phase of the nursing process. This includes vital sign, behaviors and other observation notice by the patient.
Data
The ______ category mirrors the planning and implementation phase of the nursing process and encompasses immediate and future nursing actions.
Action
The _____ category reflects evaluation phase of the nursing process.
Response
It refers to a digital version of a patient’s medical history, including demographic information, past medical history, medications, vital signs and more.
EHR (electronic health record)
What are the advantages of EHR
-digital patient chart
-comprehensive data
-interoperability
-improve care
-efficiency and cost savings
A structured system for organizing and documenting patient information around identified problems. Focuses on a systematic approach to understanding and managing a patient’s health issues.
Problem oriented medical record (POMR)
What are the components of POMR
-define information
-problem list
Is a summary of treatment plan for each problem on the problem list, should be updated at every visit and readily available to all healthcare team members.
The management plan
