Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
arrative Charting
Can use with source- or problem-oriented system Story of care in chronological format Tracks the client s changing status Can be lengthy and disorganized
SOAP Charting
S for Subjective data O for Objective data A for Assessment P for Plan Some Add IER
I for Intervention E for Evaluation R for Revision
PIE Charting
P for Problem I for Interventions E for Evaluation Used only in problem-oriented charting Establishes an ongoing plan of care
Focus Charting
Highlights the client s concerns, problems, or strengths Occurs in 3 columns:
Column 1: Time and date Column 2: Focus or problem being addressed Column 3: Charting in a DAR format: Data, Action, Response
Admission Database
Chief complaint or reason for admission Physical assessment data Vital signs Allergy information Current medications ADL status and discharge planning information/ needs Data about client support system and contact information
Flow Sheets
Record routine aspects of care (hygiene, turning) Document assessments; usually organized according to body systems Track client response to care (wound care, pain, intravenous fluids) Graphic records - used to record vital signs Intake and output record
Discharge Summary
Time of departure and method of transportation Name and relationship of person(s) accompanying client at discharge Condition of client at discharge Teaching conducted and handouts/informational matter provided to client Discharge instructions (including medications, treatments, or activity) Follow-up appointments or referrals given
Occurrence Events
Also known as Incident reports Closely follow each institution's procedure for how to report and document an Incident Report
Computerized Charting
Confidentiality is important Protect client confidentiality when doing/using the computer
Reporting
Informing other caregivers about the client condition
Nurse to nurse; nurse to physician
Change-of-Shift Report
May be:
Verbal Through walking rounds Taped report
Change-of-Shift Report
Client demographics and diagnoses Relevant medical history Significant assessment findings Treatments (e.g., wound care, breathing treatments) Upcoming diagnostics or procedures Restrictions (e.g., diet, activity, isolation) Plan of care for the client Concerns
Change-of-Shift Report
Keep It CUBAN:
Transfer Reports
Your contact information Client demographics, diagnoses, reason for transfer Family contact information Summary of care Current status, including medications, treatments, 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 if the receiver has any questions
Telephone orders:
Received by phone and transcribed onto chart order sheet Have an increased risk for errors
Telephone Orders
Write the order only if you heard it yourself Make sure the verbal orders make sense with the client s status Repeat the order Spell unfamiliar names; pronounce digits of numbers separately
continued
Telephone Orders
Directly transcribe the order on the chart
Date/time Text TO followed by provider Your signature
s name
Documentation Do
s and Don
ts
Be accurate and nonjudgmental Adhere to the requirements for reimbursement Provide details about the client s condition, nursing interventions provided, and client response Document legibly and as soon as possible
Documentation Do
s and Don
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Record significant events or changes in condition Any attempts you have made to contact the primary care provider Chart teaching performed Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client
Documentation Do
s and Don
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Do not chart that you have filled out an occurrence report Chart any client refusal of treatment or medication Document any spiritual concerns expressed by the client and your interventions
Documentation Do
s and Don
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Always use black or blue ink for handwritten notes Date and time all notes Avoid subjective terms Use proper spelling and grammar Use only authorized abbreviations Document complete data about medications
Documentation Do
s and Don
ts