Save
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account. Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Chap15documentation

QuestionAnswer
What is the purpose of client records? Communication,planning, auditing, research, education, reimbursement, legal documentation, and health care analysis.
What is source oriented record? Narrative charting. It is traditional and in story-like format.
What are the components of the Source-Oriented Record? Admission sheet,Inital nurse assessment, Graphic record,Daily care rec,special flow sheets, med rec, nurses'notes,medical hist. & phys.exam,physician's order forms,physician's progress notes,Consult rec, Diag rep,consult rep,client discharge plan &ref sum
What is the problem-oriented med record (POMR)? Estab by Lawrence Weed in 1960s. Data is arranged according to the problem, not the source of info.
What does the POMR include? Database,Problem list,plan of care,and progress notes.
What format is the progress notes in the POMR? SOAP Subjective, Objective, Assessment, and Plan.
What is PIE? It groups info into 3 categories. Problem ,Interventions, and Evaluation. The flow sheet uses specific assessment criteria in a particular format such as human needs or functional health patterns. The time parameters can vary from minutes to months.
What is focus charting? intented to make client and client concerns and strengths the focus of care. Three columns used: date and time,focus and progress notes. Progress notes are organized into data,action, and response.
What is charting by exception (CBE)? is when only abnormal or significant findings or exceptions to the norms are recorded.
What are some guidelines for documentation? Date and time, timing,legibility, permanence, and terminology.
Created by: 706661534
Popular Nursing sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards