NUR1010, Documenting and Reporting

  1. health record is a legal documentation
    • legal evidence of the care given to the client
    • (timely, appropriate, minimum legal standards...)
  2. PIE
    • Problem-Intervention-Evaluation
    • system organizes info according to the patient's problems + requires keeping a daily assessment record and progress notes
    • -> no need for seperate careplan
    • -> nursing focused rather than medical focused
    • '
    • for problem: use data from original assessment-> for appropriate nursing diagnosis

    intervention: document nursing actions to take for each nursing diagnosis

    evaluation: document patient's response to treatments

    • critics: just focussing on problems
    • ! does not document planning portion of nursing process
  3. SOAP(IER)
    often used to write nursing and other progress notes

    (sourceoriented, poblem oriented and EHRs)

    • Subjective
    • Objective
    • Assessment
    • Plan

    • (Intervention
    • Evaluation
    • Revision)
  4. POR
    Problem-Oriented Record System

    • organized according to specific problem
    • database (not in SOAP)
    • problemlist
    • initial plan
    • progress notes
    • discharge summary
  5. Focus Charting
    • look at patient from a positive status (not like problem charting)
    • -> uses assessment data
    • -> to evaluate patient's strength's, problems and concerns
    • -> identifies necessary revision to the care plan as you document each entry
    • ->focus often nursing diagnosis

    good system in acute care and where same procedure is done frequently
Card Set
NUR1010, Documenting and Reporting
NUR1010, Documenting and Reporting