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CMIE ch 4 review
types of charting, acronyms, key points for each
| Something | Something Else |
|---|---|
| Place where narrative is most useful | acute and ltc, home, ambulatory |
| what are parts of the POMR | database, care plan, problem list, progress notes, discharge summary |
| what are parts of narrative MR | progress notes, flow sheets to supplement care plan |
| what is format of progress notes in POMR | SOAP, SOAPIE, SOAPIER |
| What does soapier stand for | subjective, objective, assessment, plan, intervention, evaluation, revision |
| what is PIE | Problem, intervention, evaluation |
| where is PIE most appropriate | acute care |
| what are parts of PIE | assessment flow sheets, progress notes, problem list |
| Format of PIE | P#1, I#1, E#1, P#2, I#2, E#2... |
| Where is POMR appropriate | ltc and acute, home care, rehab, mental health |
| Where is FOCUS most appropriate | acute care and ltc |
| parts of FOCUS record | progress notes, flow sheets, checklists |
| what are foci of FOCUS | nursing diagnoses; also signs or symptoms, patient behavior, special need, acute changes, or significant events |
| what is format of progress notes in FOCUS | DAR |
| what is DAR | data, action, response |
| CBE utilizes which parts of record | care plan, flow sheets, graphic record, and progress notes |
| nursing care plan for CBE is based on what | nursing diagnoses |
| what is format of progress notes for CBE | SOAP, SOAPIER |
| what is FACT | flow sheet, assessment, concise, timely |
| what are parts of FACT | assessment sheet, flow sheets, progress notes |
| format of progress notes in FACT | DAR |
| Where is FACT appropriate | acute and ltc |
| what is Kardex made up of, and what MR type possesses it | database and care plan; it is in Core (with DAE) |
| what are parts of Core | Kardex, flow sheets, progress notes |
| where is computerized MR appropriate | actue, ltc, home, ambulatory |
| what does computerized MR include | progress notes, flow sheets, care plan, database, teaching plan |
| what format are progress notes in computerized MR in | evaluative statements, expected outcomes, learning outcomes |
| in Core, what is DAE | data, action, evaluation |
Created by:
nursingstudent
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