NUR 155 Exam 1 Documentation (Ch. 15) fully solved

Source-Oriented Records One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records Fragmented data -- making it difficult to track problems chronologically with input from different groups of professionals data is an example of a disadvantage of what? Narrative Charting Consists of written notes that include routine care, normal findings, and client problems. Problem-Oriented Medical Records (POMR) Data arranged according to client problem rather than the source of the information. SOAPIER Data Subjective data, objective data, assessment, plan, interventions, evaluation, revision Subjective data Information obtained from what the clients tells you. Objective Data Information that is measured or observed by use of the senses. Assessment An interpretation or inclusion drawn about the subjective and objective data. Plan Preparation of the care designed to resolve the stated problem. Interventions The specific care that has actually been performed by the caregiver. Evaluation The client's responses to nursing interventions and medical treatment. Revision Care plan modifications suggested by the evaluation. Problem-Oriented Medical Records (POMR) Database, Problem list, Plan of care, Progress notes, are Four basic components of__________. Problem, Interventions, and Evaluation What are the three parts of the PIE documentation model? Focus Charting Charting that is intended to make the client and clients concerns and strengths the focus of care. Data, Action, Response Progress notes are organized into DAR. What does DAR stand for? Charting by Exception (CBE) Charting where only abnormal or significant findings or exceptions are recorded. Electronic Health Record (EHR) Used to manage large volumes of information required in contemporary health care. Used to store the client's database, new data, create and revise care plans and document client's progress. Documenting Nursing Activities (DNA) Record should describe the client's ongoing status and reflect the full range of the nursing process. Admission Nursing Assessment (ANA) Completed when the client is admitted to the nursing unit. Includes: Demographics, Baseline data, and Critical elements. Nursing Care Plans (NCP) Provides evidence of the nursing process . Kardex A widely used, concise method of organizing and recording data about a client. A summary of client plan of care and status Flow Sheets Allows nurses to record nursing data quickly and concisely. Includes: Graphic record, Intake and output, Medication administration record, and Skin assessment record. Graphic Record This record indicates body temperature, pulse, blood pressure, and weight. Intake and Output Record (IOR) All routes of fluids gained and all routes of fluid loss are recorded on this form. Medication Administration Record (MAR) Flow sheet that usually includes: Patient Name, Allergies, Drug name, Dosage strength, Route, Frequency. often referred to as "drug chart". Skin assessment record (SAR) An integumentary or wound assessment, often recorded on a flow sheet. Progress Notes Provides information about the progress made toward achieving desired outcomes. Includes information about client problems and nursing interventions.