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
Author
clugger
ID
270241
Card Set
NUR1010, Documenting and Reporting
Description
NUR1010, Documenting and Reporting
Updated