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Face sheet
Patient data-name, address, phone, next of kin, hospital ID number, religion, insurance CO, place of employment, admitting physician, admitting diagnosis
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Six ways to chart
- Source oriented (narrative)
- POMR
- Focus
- Charting by exception
- Computer assisted
- Case mgmt system
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Advantages of source oriented charting (narrative)
- Aspects of all steps of the nursing process
- Baseline condition for each shift
- Chronological order
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Disadvantages of source oriented charting (narrative)
- Extensive charting time
- Lengthy entries discouraging team members from reading all parts
- Both abnormal and normal findings
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Source oriented charting focuses on
Patient's disease
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Problem Oriented MR contains
- Database
- Problem list
- Plan
- Progress notes
- Discharge Summary
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Two types of problem oriented MR
SOAP and PIE
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SOAPIER
- Subjective
- Objective
- Assessment
- Plan
- Implementation
- Evaluation
- Revision
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PIE
- Problem
- Intervention
- Evaluation
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Advantages of POMR
- Provides documentation of comprehensive care
- Problem solving approach
- Improves continuity of care
- Easy to audit
- Reinforces applicatino of the nursing process
- Requires continual evaluation and revision of the plan of care
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Disadvantages
- Loss of chronological charting
- More difficult to track trends
- Fragments data due to many flow sheets
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Focus charting is similar to
POMR but changes problem (negative) to focus (positive)
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Focus charting is directed at a
nursing diagnosis, patient problem, concern, sign, symptom, or event
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Three components of focus charting
- Data
- Action
- Response
- (sometimes, Evaluation)
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Advantages of focus charting
- Compatible with use of nursing process
- Shortens charting time
- Focus not limited to patient problems or nursing diagnosis
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Disadvantages of focus charting
- If database is not sufficient, patient problems may be missed
- Does not adhere to chartingb with focus on nursing diagnoses and expected outcomes
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Charting by exception is based on
All standards of practice are carried out and met with normal response unless otherwise documented
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Advantages of charting by exception
- Highlights abnormal data and patient trends
- Decreases narrative charting time
- Eliminates duplication of charting
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Disadvantage of charting by exception
- Requires development of detailed protocols and standards
- Requires retraining staff
- Nurses become used to not charting that important data are sometimes omitted
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Advantages of computer aided charting
- Date and time automatic
- Legible notes
- Fast communication
- Can reduce errors
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Disadvantages of computer aided charting
- Sophisticated security system needed
- Large upfront cost
- Can take a long time to set up
- Computer down time
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Guidelines for charting about a sign or symptom
- Quality
- Quantity
- Chronology
- Setting
- Aggravating or alleviating factors
- Associated manifestations
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Charting is organized by
Nursing diagnosis or problem
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If you make an error while charting
Write "error" above it and add the date and initials
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If you have a late entry
Write the time of the entry, circle it, and write "late entry" and your initials about the time
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Who provides the guideline for required documentation
American Nurses Association
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Difference between narrative and POMR
The separation of notes on medical care and nursing care
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When MR is needed as evidence in court, it is the property of the
patient
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Advantage of POMR when using interdisciplinary system is that
All menbers of the team chart in a sequential order
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When charting the patient's condition and nursing care, the nurse records
Patient statements and observed behaviors
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