Purpose of documentation - ANSWER if it isn't recorded, it didn't
happen, to identify actual and potential health problems, plan
appropriate care, evaluate the pt's responses to tx,
What should be documented - ANSWER anything done on behalf of
the pt so that you can make more informed decisions for their care
Failure to document - ANSWER negligence
Malpractice
Fraud
Abuse
Chart by exception (CBE) - ANSWER Complete physical assessments,
observations, vital signs, IV site and rate, and other pertinent data
charted at the beginning of each shift
During shift details can be added
Flow sheet are used to reduce time
Focus - ANSWER Where the patient problem is and where the basic
needs
Nursing process used with FOCUS on patient needs
DARE - ANSWER Data- Subjective and objective
Action- Action ( planning and implementation)
Response and evaluation
Education and patient teaching
SOAPE ( problem-oriented) or SOAPIER - ANSWER Patient problem
oriented
, The nursing process begins with ASSESSMENT, which is
SUBJECTIVE-reports what the patient says
OBJECTIVE-records what the nurse observes
ANALYSIS-identifiers a nursing diagnosis
PLAN-describes nursing interventions
IMPLEMENTATION-records how those actions were carried out
EVALUATION-reports the actual patient outcome or response
REVISION-any changes
What are indicate reports and why are they completed ? - ANSWER
Used for any event not consistent with routine care of a patient
critical pathways "critical" - ANSWER -Coordinates medical and nursing
interventions
-All disciplines develop integrated care plans for projected length of stay
for specific case type
-Monitor patients progress and documentation tool
Diagnosis-related groups (DRGs) - ANSWER System classifying
patient by age, diagnosis and surgical procedure, producing 300
different categories used in predicting the use of hospital resources,
including length of stay
What makes home health care documentation unique? - ANSWER
Different health care providers need access.
Confidentiality - ANSWER Respecting the privacy of patient only
allowed to see patient chart if nurse took on that patient case
DONT NOT VIOLATE HIPPA
Nursing Process steps - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
happen, to identify actual and potential health problems, plan
appropriate care, evaluate the pt's responses to tx,
What should be documented - ANSWER anything done on behalf of
the pt so that you can make more informed decisions for their care
Failure to document - ANSWER negligence
Malpractice
Fraud
Abuse
Chart by exception (CBE) - ANSWER Complete physical assessments,
observations, vital signs, IV site and rate, and other pertinent data
charted at the beginning of each shift
During shift details can be added
Flow sheet are used to reduce time
Focus - ANSWER Where the patient problem is and where the basic
needs
Nursing process used with FOCUS on patient needs
DARE - ANSWER Data- Subjective and objective
Action- Action ( planning and implementation)
Response and evaluation
Education and patient teaching
SOAPE ( problem-oriented) or SOAPIER - ANSWER Patient problem
oriented
, The nursing process begins with ASSESSMENT, which is
SUBJECTIVE-reports what the patient says
OBJECTIVE-records what the nurse observes
ANALYSIS-identifiers a nursing diagnosis
PLAN-describes nursing interventions
IMPLEMENTATION-records how those actions were carried out
EVALUATION-reports the actual patient outcome or response
REVISION-any changes
What are indicate reports and why are they completed ? - ANSWER
Used for any event not consistent with routine care of a patient
critical pathways "critical" - ANSWER -Coordinates medical and nursing
interventions
-All disciplines develop integrated care plans for projected length of stay
for specific case type
-Monitor patients progress and documentation tool
Diagnosis-related groups (DRGs) - ANSWER System classifying
patient by age, diagnosis and surgical procedure, producing 300
different categories used in predicting the use of hospital resources,
including length of stay
What makes home health care documentation unique? - ANSWER
Different health care providers need access.
Confidentiality - ANSWER Respecting the privacy of patient only
allowed to see patient chart if nurse took on that patient case
DONT NOT VIOLATE HIPPA
Nursing Process steps - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
