SOAPS
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-Subjective data
-Objective data
-Assessment
-Statement of Medical Problem(s)
-Plan
-Short-term and long-term goals to relieve client's problem
7 Essential Components of Quality Nursing Documentation
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, 1.Centers on client
2.Reflects actual work of nurse
3.Reflects objective clinical judgment of nurse
4.Proceeds in logical, sequential manner
5.Recorded concurrently with events
6.Records variances/adverse events in findings & care
7.Fulfills legal requirements
Quality Nursing Documentation: Records variances in findings and care
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Incident/Occurrence Report
Formal record of an unusual occurrence or accident
◦Report all errors even if no adverse impact on client
Not part of medical record
◦Never reference in nursing notes or any other section of health record
Organizational Report
◦Analyze event
◦Identify areas for quality improvement
◦Formulate strategies to prevent future occurrences
Goal: create safer processes/procedures for clients/staff
Organization of Health Record Systems: Source Oriented
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-Different disciplines document in separate sections of record
-Some interdisciplinary charting may be done
Source-oriented (SO) charting is a narrative recording by each member
(source) of the health care team charts on separate records. SO charting is
time-consuming and can lead to fragmented care.
, 4 C's of documentation and what must it include?
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-Clear
-Concise
-Comprehensive
-Correct
Must include: demographic data, Vitals, subjective/objective data,
medications,etc.
Quality Nursing Documentation: Reflects Objective Clinical Judgment of Nurse
Give this one a try later!
Give this one a try later!
-Subjective data
-Objective data
-Assessment
-Statement of Medical Problem(s)
-Plan
-Short-term and long-term goals to relieve client's problem
7 Essential Components of Quality Nursing Documentation
Give this one a try later!
, 1.Centers on client
2.Reflects actual work of nurse
3.Reflects objective clinical judgment of nurse
4.Proceeds in logical, sequential manner
5.Recorded concurrently with events
6.Records variances/adverse events in findings & care
7.Fulfills legal requirements
Quality Nursing Documentation: Records variances in findings and care
Give this one a try later!
Incident/Occurrence Report
Formal record of an unusual occurrence or accident
◦Report all errors even if no adverse impact on client
Not part of medical record
◦Never reference in nursing notes or any other section of health record
Organizational Report
◦Analyze event
◦Identify areas for quality improvement
◦Formulate strategies to prevent future occurrences
Goal: create safer processes/procedures for clients/staff
Organization of Health Record Systems: Source Oriented
Give this one a try later!
-Different disciplines document in separate sections of record
-Some interdisciplinary charting may be done
Source-oriented (SO) charting is a narrative recording by each member
(source) of the health care team charts on separate records. SO charting is
time-consuming and can lead to fragmented care.
, 4 C's of documentation and what must it include?
Give this one a try later!
-Clear
-Concise
-Comprehensive
-Correct
Must include: demographic data, Vitals, subjective/objective data,
medications,etc.
Quality Nursing Documentation: Reflects Objective Clinical Judgment of Nurse
Give this one a try later!
