Documentation PPT (& documentation systems)

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  1. What parts of documenting is important regarding legal issues? (3)
    Date & time of entry.
  2. When should you write a progress (narrative) note? (4)
    • 1) admission, transfer, discharge
    • 2) procedure is performed
    • 3) post-surgery
    • 4) contacting physician about change in PT status
  3. When is the only time you should access Pt info.?
    On a NEED TO KNOW basis.

    -Direct caregivers.
  4. Doc. systems:

    What is an SOR?
    Advantages (2)
    Disadvantages (2)
    Source-Oriented Records.

    • Ad: Easily chartable, easy to read specific info.
    • Dis: Tracking problems; may decrease comm. btwn providers.
  5. Doc systems:

    What format does it use?

    Advantages 1
    Disadvantages 2
    • Problem-Oriented Medical Records
    • Uses SOAP format.

    • Ad: Easy tracking of problem list.
    • Dis: Unfamiliar doc. system to providers; extra work to maintain problem list.
  6. Doc systems:

    SOAP charting w/ POMR.
    What is SOAP?
    Give description of acronym.
    • S: subjective data
    • O: objective data
    • A: assessment: conclusions & interpretation of sub. and obj. data.
    • P: plan. Plan of Care designed to solve problem.
  7. Doc systems:

    What is PIE?

    Advantages 2
    Disadvantages 1
    • Problem, Intervention, Evaluation.
    • Uses: progress notes, flow sheets
    • Ad: NO care plan needed; maintenance of care

    Dis: tracking problems is difficult.
  8. What is Focus Charting?

    What notes are used (1)? Organized into DAR. What is DAR?

    Advantage 1
    Focuses on client's CONCERNS & STRENGTHS.

    Progress Notes

    • D: (data) assessment & nursing observations.
    • A: (action) planning
    • R: (response) evaluation

    Ad: HOLISTIC Pt perspective.
  9. What is the most commonly used doc. system?

    What does it use for assessments (2)?
    CBE: Charting By Exception.

    Uses flow sheets & graphic charts.
  10. Which doc. system is used to report Pt care?

    What other "reports" is it used for? (5)
    SBAR (situation, background, assessment, recommendation)

    • 1) change of shift reports
    • 2) telephone reports
    • 3) xfer & discharge reports
    • 4) incident reports (not in Pt MR)
    • 5) reports to family members
Card Set
Documentation PPT (& documentation systems)
Documentation PPT notes Weeks 1-3 for Exam 1 (9/22/14)
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