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Unit 9: Inter-Professional Collaboration
Compare different documentation methods
8
Nursing
Undergraduate 2
04/30/2012

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Term



Different Documentation Methods

(5)

Definition

1.  Source-Oriented Records


2.  Problem-Oriented Medical Records (POMR)


3.  Focus Charting


4.  Charting by Exception (CBE)


5.  Case Management Model

Term

 



Source-Oriented Records

(4)

Definition
  • Traditional
  • Each discipline make notations in separate section
  • Info about a specific problem distributed throughout  
  • Narrative charting used = no right/wrong order

Pro: Convenient to trace info specific to one's discipline

Con: Info a/b particular problem scattered throughout/ no chronological order; decreased communication among providers, incopmlete picture of pt. care, lack of care coordination

Example:  Papercharts w/ specified tabs

Term


Problem-Oriented Medical Record (POMR)

(3)

Definition
  • Data arranged according to problem rather than the source
  • Team contributes to problem list, plan of care & progress notes
  • Uses SOAP(IER) documentation rather than Narrative charting [Subjective, Objective, Assess, Plan, Intervention, Eval,Revise]


Pros: Encourage collaboration & Easier to track status of each problem

Cons: Less efficient documentation process & Constant vigilance to maintain up-to-date problem list

Term

 


Focus Charting

(4)

Definition
  • Focus on client concerns & strengths 
  • Progress notes organized in DAR format [Data, Action, Response]  DATA= Assess; ACTION= Plan & Implementation, ASAP/Future/Changes; RESPONSE= Evaluation & describes Clients Response to care
  • Provides holistic perspective of patient/ pt. needs
  • Nursing process framework for progress notes

ExampleD) Guarding abd incision; facial grimace; rates pain 8,

 A) Administered morphine sulfate 4mg IV,

 R) Rates pain 1; states willing to ambulate

Term

 


Charting by Exception (CBE)

(4)

Definition
  • Incorporates 1) flow sheets, 2) standards of care, 3) bedside chart forms
  • Agencies develop standards of nursing practice
  • Only abnormal or significant findings/ Exceptions to standards are recorded in nurse's notes 
  • Documentation according to standards involves a check mark

Pros: Eliminates lengthy, repetitive notes & Obvious changes n condition evident

Cons: Automatically assumed that nurse assessed for abnormal conflicts w/ common mindset "not charted, not done"



Term

 


Case Management Model

(5)

Definition
  • Quality, cost effective care delivered within an est. length of stay
  • Multidisciplinary approach to planning/documenting care 
  • Critical Pathways= identify outcomes certain groups of pts are expected to acheive per day of care along w/  interventions necessary for each day
  • Progress notes typically use Charting By Exception (CBE)
  • Documentation of variance for goals not met to include            1) Corrective actions and/or 2) Justifications behind actions taken
Pros: Promotes teamwork, helps decrease length of stay, makes efficient use of time
Term

 

 

 

Critical Pathways

Definition

 

identify outcomes that certain groups of pts are expected to acheive on each day of care, along w/ the interventions necessary for each day

Term

 

 

 

Variance


 

What does a nurse do when a variance occurs?

Definition


A goal that is not met; a deviation to what is planned on the critical pathway or unexpected occurrences that affect the planned care or the client's responses to care.


When a variance occurs...

Nurse writes note documenting the unexpected event, the cause, and actions taken to correct the situation or justify the actions taken

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