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Documentation-P&P

NU110

QuestionAnswer
Malpractice mistakes that are common on charting failing to: 1) record pertinent health/drug info 2) record nursing actions 3) record meds given 4) drug reactions or changes in clients condition 5) writing illegible or complete records 6) to document a discontinued medication
purposes of records 1) communication 2) legal documentation 3) financial billing 4) education 5) research 6) auditing-monitoring
Confidentiality 1) pt. educ. on privacy protection 2) ensuring pt. access to their medical records 3) rcing pt. consent before info is released 4) providing recourse if privacy protection are violated
quality of documentation factual, accurate, complete, current, organized
SOAP subjective, objective, assessment, plan
SOAPIE subjective, objective, assessment, plan, intervention, evaluation
PIE problem, intervention, evaluation
Focus charting - DAR data, action, response
Problem-Oriented Medical Records (POMR) database, problem list, nursing care plan, progress notes
Organization of Traditional Source Record -Admission sheet -Physician's order sheet -Nurse's admission assessment -Graphic sheet & flow sheet -Medical history & examination -Nurses' notes -medication records -Physician's progress notes -health care disciplines' records -discharges summar
SBAR Situation, Background, Assessment, Recommendation
Created by: chinkychunsa