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nursing chpt 17

Fundamentals of nursing chpt 17 Documenting, reporting, and conferring

QuestionAnswer
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