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What's in a client's chart? And what's are the principles behind a client's chart?
- 1. A legal record
- 2. Written documentation of the care received
- 3. Provides for continuity of care
- 4. Indicates compliance with your nurse practice act
- 5. Evidence of quality of nursing care
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This pt record has database, problem list, plan of care, and progress notes. What is this pt record known as?
Problem Oriented Medical Record
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This pt's record is traditional, each discipline with own documentation section. This record is known as...
Source oriented Record
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This pt record has flowsheets, standards of care, ease of data retrieval. This record is known as...
Electronic Record
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"Telling the story" is what kind of documentation system?
Narrative charting
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Outline format is what kind of documentation system?
SOAPIE
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What does SOAPIE stand for?
- S ubjective data
- O bjective data
- A ssessment
- P lanning
- I ntervention
- E valuation
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This documentation system only deals with "problems".
PIE
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What does PIE stand for?
- P roblem
- I intervention
- E
valuation
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This documentation system includes flow sheets and standards of care.
Charting By Exception
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This documentation system is nursing process based (we use @NVCC)
Focus charting
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This has multidisciplinary plan of care, identified outcomes for certain medical Dx, variance documentation, this documentation system is focuses on what's expected and it's known as...
Critical Pathways
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What is are some examples of Critical Pathways?
Pneumonia Pathway, Joint Replacement Pathway
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This documentation form includes demographics, ADL needs, treatments, and tests.
Kardex
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This documentation form includes the graphic record, VS, I&O, med administration record, skin assessment, pt teaching, and restraints.
Flow Sheets
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These forms include document assessment, care planned and provided, progress toward goals.
Progress Notes
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What are the legal guidelines for charting?
- 1. Write in black ink(photocopies better)
- 2. Don't erase, white out, scratch out
- 3. Don't discard legal records
- 4. Don't chart before it's done (falsify records, fraud)
- 5. Don't leave blank spaces
- 6. Chart only for yourself
- 7. Date and time each entry
- 8. Sign each entry with first and last name and title, affiliation
- 9. Don't share computer passwords
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When you write an error, what do u do?
One line thru error, above write "omit" or "mistaken entry" and initials
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What are the ABCs of charting?
- A ccurate
- B rief and concise
- C omplete
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