Question | Answer |
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 |