Chap 7: Documentation Of Nursing Care

Front 1

Medical record

Back 1

(as called chart) Contains all the orders, tests, treatments, and care that occurred during the time the person was under the care of the health care provider. A key communication tool for the professionals involved in the care of the patient. A legal record that can be used as evidence of events that occurred or treatment that was given. Property of health care facility. Patient does not always have a right to the info in the chart.

Front 2

Documentation

Back 2

(as called charting) Used to track the application of the nursing process. Shows progress towards the expected outcomes listed on nursing plan.

Front 3

Methods of documentation

Back 3

(1)Source-orientated(narrative) charting, (2)Problem-orientated medical record charting(POMR), (3)Focus charting, (4)Charting by exception, (5)Computer-assisted charting, and (6)Case management system charting

Front 4

Advantages of Source-Oriented(Narrative) charting

Back 4

(1)Gives patient condition and care in chronological order, (2)Indicates patients baseline for each shift and (3)Includes aspects of all steps of nursing process

Front 5

Source-orientated(narrative) charting,

Back 5

Focuses on the patients disease. Separate forms for each professional caring for patient. Notes written without any standardized structure/form. Patient care is put in chronological order. Assessments follow a body systems format. (ex: set of dated and timed journal entries).

Front 6

Problem-orientated medical record charting(POMR)

Back 6

Focuses on the problems experienced by the patient as a result of being ill (patient status) or on the defined nursing diagnosis reflecting those problems and not medical/nursing care.Emphasis the problem solving approach to patient care. A method of communicating what, when and how something is done. Five basic parts are: The database, problem list, plan, progress notes and discharge summary. Progress notes use soapie or soapier format.

Front 7

Disadvantages of Source-Oriented(Narrative) charting

Back 7

(1)Difficult to separate pertinent from irrelevant info, (2)extensive charting time for each shift and (3) discourages health care professionals from reading all parts of the chart

Front 8

Focus charting

Back 8

centers on the patient from a positive perspective by replacing problem with focus. Directed at nursing diagnosis, patient problem(pressure sore), concern(decreased food intake), sign(fever), symptom(anxiety) or event(surgery). Nurses notes are done in DAR or DAE format

Front 9

SOAP, SOAPIE, SOAPIER

Back 9

Format used for progressive notes in POMR charting. Used in each entry. Component(i.e S) can be omitted if not necessary (i.e. if there is no subjective data ).
(S)ubjective info, (O)bjective data, (A)ssessment data, (P)lan, (I)mplementation, (E)valuation and (R)evision.

Front 10

Charting by exception

Back 10

Based on assumption that all standards of practice are carried out and met with the expected response unless otherwise documented. Nurses only need to document abnormal findings or responses correlated with the nursing diagnosis listed on care plan. Direct opposite of adage "if it wasn't charted it wasn't done".Presents legal problems if chart is called into court.

Front 11

Computer-assisted charting

Back 11

where data is inputed into the computer

Front 12

Case management system charting

Back 12

which tracks variances from the clinical pathway

Front 13

Advantages to Problem-Oriented Medical Record charting

Back 13

(1) Provides documentation of comprehensive care, (2)Promotes problem-solving approach to care, (3)Improves continuation of care and communication by keeping all relevant data in one place, (4) allows for easy auditing, (5)reinforces application of nursing process, and (6)requires continual evaluation and revision of plan of care.

Front 14

Disadvantages to Problem-Oriented Medical Record charting

Back 14

(1)loss of chronological charting, (2)difficult to track trends in patient status, and (3) it fragments data due to increase in flow charts used.

Front 15

Pie Charting

Back 15

Type of POMR charting. Four parts (A)ssessment(only used when assessment data is abnormal), (P)roblem identification, (I)nterventions and (E)valuation. Follows the nursing process and uses nursing diagnosis(kept under P). Care plan placed in nurses' progress notes.Notes differs from SOAP;Does not use traditional nursing care plan or require narrative charting. Daily charting done on special flow sheet that are marked with problem number and title.

Front 16

DAE or DAR

Back 16

Note format in focus charting.
(D)ata, (A)ction, (E)valuation or (D)ata, (A)ction, (R)esponse. Data can be subjective or objective. Actions include any interventions. Response/ Evaluation describes the outcomes and whether the goal has been met.

Front 17

Advantages of Focus charting

Back 17

(1)Compatible with nurses process, (2)Shortens charting time by using checklist and flow sheets and (3)not limited to patients problem or nurses diagnosis.

Front 18

Disadvantages of Focus charting

Back 18

(1) database is not sufficient, problems may be missed, and (2) doesn't adhere with the focus on nurses' diagnosis and expected outcomes.

Front 19

Protocol

Back 19

standard procedures

Front 20

Advantages of Charting by Exception

Back 20

(1)Highlights abnormal data and trends, (2)decreases narrative charting time, (3)eliminates duplication of charting

Front 21

Disadvantages of Charting by Exception

Back 21

(1) requires development of detailed protocols, (2)requires retraining staff to use, and (3)nurses get to use to not charting that important data could be omitted.