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NRS Documentation

test 1

Purpose of the chart communication, permanent record for accountability, peer review, reimbursement, legal record of care, teaching tool, and research and data collection
Types of patient records source-oriented and problem-oriented
source-oriented chart each healthcare discipline documents in their own section
Problem-oriented chart based on scientific problem-solving method; organized according to the health problem
problem oriented chart includes database,problem list, plan of care, and progress notes (everybody documents here)
methods of charting narrative style, SOAPE/SOAPIER, Focus, PIE, charting by exception
charting by exception only abnormal assessment findings are documented; effort to decrease length and repetition
PIE charting Problem Intervention Evaluation
Focus charting DARE Data Action Response Education
SOAPE/SOAPIER charting Subjective Objective Assessment Plan Evaluation Intervention Revision
Narrative charting descriptive form including pt. problem, care and treatment provided; as well as pt. response
computer charting pros/cons PROS fast, legible, auto date/time CONS can risk confidentiality, can be hard to make corrections if not made quickly
T or F never use military time False
00:00= midnight or 12am
12:00= 12pm or noon
18:00= 6pm
23:00= 11pm
1am 01:00
6am 06:00
T or F Rn is responsible for initial assessment upon admission True
T or F any sheet patient info is documented on may only include the patient date of birth False. It should have their at least their name on every page
T or F when in doubt write it out True
when giving medications, especially PRN... Always chart follow-up response 30 minutes after
T or F Empty lines in a chart are okay if there is nothing to note False. Any skipped lines or empty lines should at least have a line drawn through them to avoid additions at later times.
T or F chart as soon as you can, even if it is prior to giving care False. only chart after care is given and as soon as possible after
Do you have to chart the type of transportation device used to transfer or discharge a pt.? yes.
Can you chart deviations without and explanation? No. there needs to always be an explanation of any deviations from the original care plan.
should you document any time the physician was contacted? Yes.
Created by: laceynickie