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21 Cards in this Set
- Front
- Back
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Change-of-shift report
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a report given to nurses on the next shift
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Chart
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a formal, legal document that provides evidence of a client’s care
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Charting
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the process of making an entry on a client record
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Charting by exception (CBE)
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a documentation system in which only significant findings or exceptions to norms are recorded
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Client record
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see Chart
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Discussion
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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
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Documenting
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see Charting or Recording
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Flowsheet
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a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications
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Focus charting
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a method of charting that uses key words or foci to describe what is happening to the client
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Kardex
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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
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Narrative charting
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a descriptive record of client data and nursing interventions, written in sentences and paragraphs
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PIE
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an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
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Problem-oriented medical record (POMR)
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data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
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Problem-oriented record
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(POR) see Problem-oriented medical record (POMR)
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Progress notes
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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
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Record
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a written communication providing formal, legal documentation of a client's progress
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Recording
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the process of making written entries about a client on the medical record
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Report
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whether oral or written, it should be concise, including pertinent information but no extraneous detail
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SOAP
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an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning
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Source-oriented record
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a record in which each person or department makes notations in a separate section or sections of the client’s chart
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Variance
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a variation or deviation from a critical pathway
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