NURSING DOCUMENTATION STUDY MATERIAL
100% VERIFIED CORRECT!
Five basic purposes for accurate and complete written patient record:
1. Written Communication
2. Permanent record for accountability.
3. Legal record of care.
4. Teaching
5 Research and data collection.
5 areas that should be covered in documentation.
1. Physical
2. emotional
3. psychosocial
4. social
5. spiritual
DRG's
Diagnosis-related groups.
What are DRG's
System that classifies patients by age, diagnosis and surgical procedure, using 300 different
categories to predict the use of hospital resources, including length of stay.
Nursing Notes
, The form on the patient's chart on which nurses record their observations, the care given and
the patient's responses.
4 most common forms of inadequate documentation.
1. Not charting the correct time when events occurred.
2. Failing to record verbal orders or failing to have them signed.
3. Charting, actions in advance to save time.
4. Documenting incorrect data.
Traditional(block) chart
Divided into blocks/sections. i.e. - admission sheets, physician's orders, progress note, H & P
examination data, nurse's admission information, care plan, nursing notes, graphs, laboratory
and x-ray examination reports.
Narrative Charting
Recording of patient care in narrative form.
Problem-Oriented Medical Record (POMR)
Organized according to the scientific problem solving system or method. Principal sections are
database, problem list, care plan and progress notes.
S.O.A.P.I.E.R.
S - Subjective information is what the patient states or feels, only the patient can provide this
information.
100% VERIFIED CORRECT!
Five basic purposes for accurate and complete written patient record:
1. Written Communication
2. Permanent record for accountability.
3. Legal record of care.
4. Teaching
5 Research and data collection.
5 areas that should be covered in documentation.
1. Physical
2. emotional
3. psychosocial
4. social
5. spiritual
DRG's
Diagnosis-related groups.
What are DRG's
System that classifies patients by age, diagnosis and surgical procedure, using 300 different
categories to predict the use of hospital resources, including length of stay.
Nursing Notes
, The form on the patient's chart on which nurses record their observations, the care given and
the patient's responses.
4 most common forms of inadequate documentation.
1. Not charting the correct time when events occurred.
2. Failing to record verbal orders or failing to have them signed.
3. Charting, actions in advance to save time.
4. Documenting incorrect data.
Traditional(block) chart
Divided into blocks/sections. i.e. - admission sheets, physician's orders, progress note, H & P
examination data, nurse's admission information, care plan, nursing notes, graphs, laboratory
and x-ray examination reports.
Narrative Charting
Recording of patient care in narrative form.
Problem-Oriented Medical Record (POMR)
Organized according to the scientific problem solving system or method. Principal sections are
database, problem list, care plan and progress notes.
S.O.A.P.I.E.R.
S - Subjective information is what the patient states or feels, only the patient can provide this
information.
