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documentation
prn doc
| Question | Answer |
|---|---|
| Change-of-shift report | a report given to nurses on the next shift |
| Chart | a formal, legal document that provides evidence of a client's care |
| Charting | the process of making an entry on a client record |
| Charting by exception (CBE) | a documentation system in which only significant findings or exceptions to norms are recorded |
| Discussion | an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem |
| Focus charting | a method of charting that uses key words or foci to describe what is happening to the client |
| Kardex | the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date |
| Narrative charting | a descriptive record of client data and nursing interventions, written in sentences and paragraphs |
| PIE | an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions |
| Problem-oriented medical record (POMR) | data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information Problem-oriented record (POR) see Problem-oriented medical record (POMR) |
| Progress notes | chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes |
| Record | a written communication providing formal, legal documentation of a client's progress |
| Recording | the process of making written entries about a client on the medical record |
| Report | whether oral or written, it should be concise, including pertinent information but no extraneous detail |
| SOAP | an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning |
| Source-oriented record | a record in which each person or department makes notations in a separate section or sections of the client's chart |
Created by:
jmeo04
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