Fundamentals of nursing chpt 17 Documenting, reporting, and conferring
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each of the black spaces below before clicking
on it to display the answer.
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| Documentation | is the written or typed, legal record of all pertinent interactions with the patient- assessing, diagnosing, planning, implementing, and evaluating.
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| 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.
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| source- oriented record | each healthcare group keeps data on its own seperate form
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| progress notes | notes written to inform caregivers of the progress a patient is making toward acheiving expectied outcomes
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| 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
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| problem oriented medical record | is organzied around a patients problems rather than around sources of information
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| SOAP | Subjective, Objective, Assessment, Plan is used during organization of a problem oriented medical record
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| 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
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| focus charting | is to bring the focus of care back to the patient and the patients concerns
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| DAR format | Data, Action, Response this format is used in the narative part in focus charting
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| Charting by exception | shorthand documentation method that makes use of well defined standards of practice
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| 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
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| 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
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| minimum data sets | a standard established by healthcare institutions that specifies the information that must be collected from every patient
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| 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
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| 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.
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| SOAP | Subjective, Objective, Assessment, Plan is used during organization of a problem oriented medical record
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| 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
🗑
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| focus charting | is to bring the focus of care back to the patient and the patients concerns
🗑
|
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| DAR format | Data, Action, Response this format is used in the narative part in focus charting
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| Charting by exception | shorthand documentation method that makes use of well defined standards of practice
🗑
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| 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
🗑
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| 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
🗑
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| minimum data sets | a standard established by healthcare institutions that specifies the information that must be collected from every patient
🗑
|
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| 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
🗑
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| 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.
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| 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
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