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21 Cards in this Set

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Change-of-shift report
a report given to nurses on the next shift
Chart
a formal, legal document that provides evidence of a client’s care
Charting
the process of making an entry on a client record
Charting by exception (CBE)
a documentation system in which only significant findings or exceptions to norms are recorded
Client record
see Chart
Discussion
an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
Documenting
see Charting or Recording
Flowsheet
a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications
Focus charting
a method of charting that uses key words or foci to describe what is happening to the client
Kardex
the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date
Narrative charting
a descriptive record of client data and nursing interventions, written in sentences and paragraphs
PIE
an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
Problem-oriented medical record (POMR)
data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
Problem-oriented record
(POR) see Problem-oriented medical record (POMR)
Progress notes
chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes
Record
a written communication providing formal, legal documentation of a client's progress
Recording
the process of making written entries about a client on the medical record
Report
whether oral or written, it should be concise, including pertinent information but no extraneous detail
SOAP
an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning
Source-oriented record
a record in which each person or department makes notations in a separate section or sections of the client’s chart
Variance
a variation or deviation from a critical pathway