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Chapter 8

client care: planning, processes, reporting, and recording

Objective data signs
Subjective data symptoms
process facilities have to follow assessment, nursing diagnosis, planning, implementation, and evaluation
basic observations ability to respond, movement, pain or discomfort, skin, eyes, ears, nose, mouth, respirations, bowels and bladder, appetite, and activities of daily living
SOAP stands for subjective data, objective data, assessment, and plan of care
PIE stands for Problem, intervention, and evaluation
assessment involves collecting information about the client
the statement, "urinary elimination, impaired" is on a care plan. this statement is a nursing diagnosis
if you make an error when recording, you should draw a single line through the error, and write "error" over it
in a long- term care facility, who has access to residents charts it depends on facility policy and procedures
Created by: mackenziemarie21