What is charting by exception?

A type of charting in which only variances from "normal" in all activities of daily living, vital signs, and assessment findings are charted as entries. Drastically reduces time spent completing paperwork, opinions vary about its efficacy and safety.

What is documentation?

The act of charting or making a written notation of all the things that are pertinent to each patient for whom a nurse provides care.

What is an Electronic Health Record?

A computerized database that typically includes present and past medical and surgical, labs, radiographic and drug info about a PT. Most also contain billing and insurance info also.

What is focus charting?

A type of charting that is focused on the patient and patient concerns problems and strengths. Unlike PIE charting there is not a constructed list of specific problems. It includes data, actions and response.

A type of flip chart with a page for each PT on the unit or floor that contains a summary of care required by the PT. It requires continual updating and maintenance by the nursing staff.

What is narrative charting?

A type of charting that details the PTs experiences during the hospital stay. It is written in chronological order and relates the PT health status from admission and through all the changes in condition, up to and including discharge status.

What is PIE charting?

A type of charting styles that is shorter and documents fewer data than the SOAPIER charting style. It only addresses the PT problems, therefore the concept of treating the PT holistically is lost. It stands for Problem, Intervention and Evaluation.

Subjective Data, Objective Data, Assessment Data and a Plan

Subjective Data, Objective Data, Assessment Data, a Plan, Intervention, Evaluation and as needed Revision.

What is the Omnibus Budget Reconciliation Act (OBRA)?

Mandates that an extensive assessment form called the Minimum Data Set (MDS) for Resident Assessment and Care Screening must be completed for each resident within 4 days of admission.

Medication Administration Records

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Chapter 5

Documentation

Question	Answer
What is charting by exception?	A type of charting in which only variances from "normal" in all activities of daily living, vital signs, and assessment findings are charted as entries. Drastically reduces time spent completing paperwork, opinions vary about its efficacy and safety.
What is documentation?	The act of charting or making a written notation of all the things that are pertinent to each patient for whom a nurse provides care.
What is an Electronic Health Record?	A computerized database that typically includes present and past medical and surgical, labs, radiographic and drug info about a PT. Most also contain billing and insurance info also.
What is focus charting?	A type of charting that is focused on the patient and patient concerns problems and strengths. Unlike PIE charting there is not a constructed list of specific problems. It includes data, actions and response.
What is a Kardex?	A type of flip chart with a page for each PT on the unit or floor that contains a summary of care required by the PT. It requires continual updating and maintenance by the nursing staff.
What is narrative charting?	A type of charting that details the PTs experiences during the hospital stay. It is written in chronological order and relates the PT health status from admission and through all the changes in condition, up to and including discharge status.
What is PIE charting?	A type of charting styles that is shorter and documents fewer data than the SOAPIER charting style. It only addresses the PT problems, therefore the concept of treating the PT holistically is lost. It stands for Problem, Intervention and Evaluation.
What is SOAP?	Subjective Data, Objective Data, Assessment Data and a Plan
What is SOAPIER?	Subjective Data, Objective Data, Assessment Data, a Plan, Intervention, Evaluation and as needed Revision.
What is the Omnibus Budget Reconciliation Act (OBRA)?	Mandates that an extensive assessment form called the Minimum Data Set (MDS) for Resident Assessment and Care Screening must be completed for each resident within 4 days of admission.
How often should the MDS be updated?	Every 3 months
What is MAR?	Medication Administration Records

Created by: Beckjim814

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