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nursing chpt 17
Fundamentals of nursing chpt 17 Documenting, reporting, and conferring
| Question | Answer |
|---|---|
| Documentation | is the written or typed, legal record of all pertinent interactions with the patient- assessing, diagnosing, planning, implementing, and evaluating. |
| Patient record | is a compilation of a patients health information. Patients record is the only permanent legal documentation that details the nurses interactions with the patient and is the nurses best defense if a patient or petient surrogate alleges nursing negligence. |
| source- oriented record | each healthcare group keeps data on its own seperate form |
| progress notes | notes written to inform caregivers of the progress a patient is making toward acheiving expectied outcomes |
| narrative notes | pregress notes written by nurses in a source oriented record are narrative notes and address routine care, normal findings, and patient problems identified in the plan of care |
| problem oriented medical record | is organzied around a patients problems rather than around sources of information |
| SOAP | Subjective, Objective, Assessment, Plan is used during organization of a problem oriented medical record |
| Pie Charting | does not develop a seperate plan of care, the plan of care is incorporated into the progress notes in which problems are identified by number |
| focus charting | is to bring the focus of care back to the patient and the patients concerns |
| DAR format | Data, Action, Response this format is used in the narative part in focus charting |
| Charting by exception | shorthand documentation method that makes use of well defined standards of practice |
| Collaborative pathways | caae management plan that is a detailed, standardized plan of care developed for a patient population with a designated dignosis or procedure; it includes expected outcomes, a list of interventions to be preformed and the seguence and timing |
| variance charting | when a patient fails to meet an expected outcome of a planned intervention is not implemented in the case mangagement model this variance from the plan is documented |
| minimum data sets | a standard established by healthcare institutions that specifies the information that must be collected from every patient |
| computer based records | these data can be distributed among many caregivers in a standardized format, allowing them to compare and unifromly evaluate patient progress easily |
| personal health records | many individuals today are preparing personal health records on the web to manage their healthcare via computer. these records contain the individuals medical history, including diagnoses, symptoms, and medication. |
| SOAP | Subjective, Objective, Assessment, Plan is used during organization of a problem oriented medical record |
| Pie Charting | does not develop a seperate plan of care, the plan of care is incorporated into the progress notes in which problems are identified by number |
| focus charting | is to bring the focus of care back to the patient and the patients concerns |
| DAR format | Data, Action, Response this format is used in the narative part in focus charting |
| Charting by exception | shorthand documentation method that makes use of well defined standards of practice |
| Collaborative pathways | caae management plan that is a detailed, standardized plan of care developed for a patient population with a designated dignosis or procedure; it includes expected outcomes, a list of interventions to be preformed and the seguence and timing |
| variance charting | when a patient fails to meet an expected outcome of a planned intervention is not implemented in the case mangagement model this variance from the plan is documented |
| minimum data sets | a standard established by healthcare institutions that specifies the information that must be collected from every patient |
| computer based records | these data can be distributed among many caregivers in a standardized format, allowing them to compare and unifromly evaluate patient progress easily |
| personal health records | many individuals today are preparing personal health records on the web to manage their healthcare via computer. these records contain the individuals medical history, including diagnoses, symptoms, and medication. |
| kardex care plan | documentation system that encompasses prescriptions for nursing care related to activites of daily living; nursing diagnoses and related patient goals and nursing orders; and the nursing care related to diagnostic measures and the medical regimen |
Created by:
cann0505
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