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
This pt record has database, problem list, plan of care, and progress notes. What is this pt record known as?
Problem Oriented Medical Record
This pt's record is traditional, each discipline with own documentation section. This record is known as...
Source oriented Record
This pt record has flowsheets, standards of care, ease of data retrieval. This record is known as...
"Telling the story" is what kind of documentation system?
Outline format is what kind of documentation system?
What does SOAPIE stand for?
- S ubjective data
- O bjective data
- A ssessment
- P lanning
- I ntervention
- E valuation
This documentation system only deals with "problems".
What does PIE stand for?
- P roblem
- I intervention
- E valuation
This documentation system includes flow sheets and standards of care.
Charting By Exception
This documentation system is nursing process based (we use @NVCC)
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...
What is are some examples of Critical Pathways?
Pneumonia Pathway, Joint Replacement Pathway
This documentation form includes demographics, ADL needs, treatments, and tests.
This documentation form includes the graphic record, VS, I&O, med administration record, skin assessment, pt teaching, and restraints.
These forms include document assessment, care planned and provided, progress toward goals.
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
When you write an error, what do u do?
One line thru error, above write "omit" or "mistaken entry" and initials
What are the ABCs of charting?
- A ccurate
- B rief and concise
- C omplete