Term
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Definition
| the act of recording client care in written form |
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Term
| communication between providers, education tool, legal document of are, QA, research, reimbursement |
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Definition
| what is the purpose of written record? |
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Term
| source-oriented document system |
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Definition
| in this type of system, disciplines are charted seperately, variety of setions and the data is scattered |
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Term
| problem-oriented documenting system |
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Definition
| in this type of documentation system, it is organized around the client, and allows greater collaboration |
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Term
| database, problem list, plan of care, progress notes |
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Definition
| what are the four components of problem oriented documentation systems? |
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Term
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Definition
| this is often the type of documenting seen in the er |
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Term
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Definition
| this type of documenting can be used with source or [problem oriented system |
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Term
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Definition
| story of care in a chronological format |
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Term
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Definition
| tracks a clients changing status |
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Term
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Definition
| this charting can be lengthy and disorganized |
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Term
S-subjective data
O-objective data
A-assessment
P- plan
I-interention
E-evaluation
R-Revision |
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Definition
| what does SOAP stand for? IER? |
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Term
P-problem
I-intervention
E-evaluation |
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Definition
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Term
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Definition
| this charting is used in problem oriented charting and establishes an ongoing plan of care |
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Term
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Definition
| this type of charting highlight the clients concerns, problems or strengths |
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Term
1. time and date
2. focus or problem being addressed
3. charting in the DAR format (data, action response) |
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Definition
| what are the three columns of Focus charting? |
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Term
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Definition
| this uses pre-printed flowsheets to document most aspects of care |
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Term
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Definition
| this type of charting enforces standard normals of assessment and a note is written if abnormal findings |
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Term
| reduces time spent charting, but can leave room for missing abnormals-omissions |
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Definition
| downfall of charting by exception? |
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Term
| est. baseline from which to monitor change, helps forecast future needs |
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Definition
| purpose of admission database? |
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Term
cheif complaint
physical assessment data
vitals
allergies
current meds
ADL status and discharge planning info
data about client support system and contact info |
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Definition
| what is recorded on admission database? |
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Term
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Definition
| these record routine aspects of care, document assessment, usually organized according to body systems |
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Term
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Definition
| flowsheets and graphic records allow for what? |
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Term
| chart time of admin and the med on the MAR |
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Definition
| what do you need to do for PRN meds? |
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Term
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Definition
| if patient refuses meds, then... |
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Term
| circle the scheduled time and write in the corresponding letter or number to indicate why med was not given |
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Definition
| if a med is ommitted or delayed then.. |
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Term
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Definition
| this is the comprehensice list of all ordered meds |
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Term
| ordered med, client allergies, docments scheduled/routine or omitted doses |
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Definition
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Term
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Definition
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Term
| demographic data, med dx, allergies, diet/activity orders, safety precautions, iv therapy orders, ordered tx, surgery, lab and tests, summeary of meds ordered, special instructions such s preferred intensity of care or iisolation orders |
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Definition
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Term
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Definition
| this is a cobined charting and care plan form that maps out on a daily basis from admission to discharge |
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Term
| in the integrated plan of care |
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Definition
| where would ou fin cliet outcomes, interentions and tx for a specific dx or condition, labwork, diagnostic testing, meds and tharapies included in the pathways? |
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Term
| nurse to nurse, or nurse to physician |
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Definition
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Term
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Definition
| this is passage of vital info related to the clients status/plan of care |
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Term
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Definition
| this is a formal record of an unusual occurrence or accident |
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Term
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Definition
| often called the EMR-electronic medical record |
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Term
| verbal, through walking rounds, taped report |
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Definition
| change of shit report may be |
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Term
| client demographics and dx, relevant medical hx, significant assessment findings, tx, upcoming diagnostics ro procedures, restrictions, plan of care for pt, concerns |
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Definition
| what does a change of shift report include? |
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Term
C-confidential
u-uninterrupted
b-brief
a-accurate
n-named nurse |
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Definition
| keep the change of shift report CUBAN |
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Term
| your contact info, client demographics, diagnoses, reason for transfer, family contact info, summary of care, current status (including meds, tx, and tubes in the client), presence of wounds or open areas of the skin, special directives (code status, preferred intensity of care, or isolation required), always ask is the receiver has any questions |
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Definition
| what do you want to include in a transfer report? |
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Term
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Definition
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Term
| time of departure and method of transportation, name and relationship of persons accompanying client at discharge, teaching conducted and handouts/info matter provded to client, discharge instructions, follow up apt or referral given |
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Definition
| what do you include in a discharge summary? |
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Term
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Definition
| these orders should not be used a routine means of communicating? |
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Term
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Definition
| these have an increased risk for errors |
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Term
write order only if you heard it yourself
make sure the verbal orders make sense with the clients status
repeat the order
spell unfamiliar names, pronounce digits of the numbers seperately
directly transcribe the order on the chart (date/time, text, TO followed by provider's name, your signature)
physician must countersign within 24 hrs. |
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Definition
| when taking a telephone order what do you wnat to do? |
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