Rnur126 Documentation

Front 1

documentation

Back 1

written or typed legal record of all pertintent interactions with the patient

Front 2

patient record

Back 2

compilation of a pt health information

Front 3

purpose of pt records

Back 3

communication with other healthcare workers, diagnostic and theraputic orders, care planning, quality review, research, decision analysis, education, legal documentation, reimbursement, historical documentation

Front 4

source oriented record

Back 4

is one where each healthcare group keeps data on its own seperate form.

Front 5

progress notes

Back 5

written to inform caregivers of the process a pt is making toward achieving expected outcomes, they are written by nurses in a source-oriented record called narrative notes and address routine care, normal findings and identified in the plan of care

Front 6

problem-oriented medical record

Back 6

oriented around the patients problems rather than around the sources of information, all information is on the same record and the entire healthcare team identifies the pt problems and works together to form a plan of care, uses the acronym SOAP

Front 7

SOAP

Back 7

S- subjective data
O- objective data
A- assessment
P-plan

Front 8

PIE charting

Back 8

system does not require a seperate plan of care, instead it is incorporated into the progress notes and they are identified by number. they are done at the beginning of each shift using a flow sheet using PIE format

Front 9

PIE

Back 9

P- problem
I- intervention
E- evaluation

Front 10

focus charting

Back 10

used to focus on the patient and pt problems uses DAR format