Term
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Definition
Documentation method that permits analytical focus on identified client problems. Chart divided includes:
Database
Problem List
Plan of Care
Progress note |
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Term
| Advantages of problem oriented records |
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Definition
Team collaborates to create plan
Provides quick identification of recognized problems |
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Term
| Disadvantages of Problem oriented records |
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Definition
Charting may be lengthy,redundant
Problem list may not be kept up to date. |
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Term
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Definition
S:Subjective: what the client says,in quotes
Example: It'"hard to take a deep breath"
NP: Data collection while assesing patient |
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Term
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Definition
Objective:
what you observed or measured
Example: Client sitting in bed. RR 28
NP: Data collection while assesing patient |
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Term
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Definition
Assessment:
interpretation,conclusion,diagnosis,problem OR progress toward goals
Example: Ineffective breathing pattern r/t _________
NP: Nursing Diagnosis |
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Term
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Definition
Plan:
what will be done about the problem
Example: Notify physcian, provide comfort
NP: Plan |
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Term
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Definition
Intervention:
Actions taken during shift
Example:Administer O2 a 3L/M, Albuterol neb tx as ordered
NP: Implementation |
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Definition
Evaluation:
How did client respond to intervention?
Example: Patient more comfortable, O2 sat 96% on O2, decreased wheezing bil resp after tx.
NP: Evauation |
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Term
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Definition
Revision:
Changes made to care plan |
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Term
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Definition
| Asssessment (includes Subjective and Objective data in support of Assessment) (Data collection/Nrsg dx) |
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Term
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Definition
Problem (assess.DC/nrsg dx
Example: Ineffective breathing pattern |
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Term
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Definition
Intervention (Implementation)
Example:Administer O2 a 3L/M, Albuterol neb tx as ordered |
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Term
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Definition
Evaluation (Evaluation)
Example: Patient more comfortable, O2 sat 96% on O2, decreased wheezing bil resp after tx. |
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Term
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Definition
| Subjective-Objective-Assessment-Plan |
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Term
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Definition
| Problem-Intervention-Evaluation |
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Term
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Definition
Focus charting
Data-Action-Response |
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Term
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Definition
Data (Subjective/Objective)
Example:
Temp,oral-101.0,skni hot,dry,pt c/o "aching all over" |
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Term
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Definition
Action (Planning/Implemetation)
Example
Call to MD, order given for tylenol 1 gram po now |
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Term
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Definition
Response (Evaluation)
Example:
Recheck 1 hr after tylenol given, Temp 99.8 orally |
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Term
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Definition
Revisions/Change in Plan
Example:
Continue with q 4 hr vital signs |
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Term
| Charting by Exception (CBE) |
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Definition
| A documetation system in which only significant findings or diviations from norm are recorded. |
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Term
| Charting by Exception (CBE)Advantages |
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Definition
Elimination of lengthy repetitve notes
Flow sheets for specifc entites
Reports changes in client condition
Easier to read and pick out problem areas. |
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Term
| Charting by Exception (CBE)Disadvantages |
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Definition
Some nurses feel uncomfortable with charting by exception.
Must fill in the blanks with N/A-no blank spaces.
Must know normal standards for healthcare organization. (minimum criteria) |
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Term
| Case Management related to Critical Pathways |
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Definition
Length of stay- predetermined
EX: CHF,Pneumona
Based on Medical Diagnosis
Interventions
Outcomes
Goals not met are called variances |
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Term
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Definition
Criteria for Length of Stay
Criteria for expected outcome
Criteria for specific interventions
Documentation of client's progress and /or variance toward goals or outcomes |
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