COMPLETE SOLUTIONS VERIFIED
Nursing Documentation
- Admission Entries
- Progress Notes ( Narrative, SOAP, PIE, Focus DAR, CBE)
Admission Entires
Done within 24 hours
Progress Notes
Track progress
Narrative
Information provided in written sentence
SOAP
Subjective, objective, assessment, plan. Focus on specific problem of pt.
PIE
Problem, Intervention, Evaluation. Plan of care incorporated to progress with outcomes
predicted
Focus DAR
Data, action, response. Broad view of any specific area of pt. Not just one specific
problem
Charting by expectation CBE
, Standards are met or checked off
IPASS the BATON
- Introduction
-Patient
- Assessment: Vitals, symptoms, diagnosis
-Situation: Current status/ circumstances, recent change in situation
- Safety concern: -
- Critical lab values, socioeconomic status
-Background:
-Comorbidities, previous episodes, current medications, and family history
- Action: Explains what actions were taken or are required - Provide rationale
- Timing: Level of urgency and explicit timing and prioritization actions
- Ownership: Identify who is responsible including pt. And family
- Next: What will happen next
Essential Fluids/ Electrolytes
Sodium: 135- 145
Potassium: 3.5-5.0
Calcium: 8.9-10.1
Magnesium: 1.8-2.3
Chloride: 95-108
Bicarbonate: 22-26
Phosphate: 1.7-2.6
Factors that can affect balance