Found Chpt 7

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Anonymous
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103997
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Found Chpt 7
Updated:
2011-09-24 15:26:14
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Test
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Test 2
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  1. Face sheet
    Patient data-name, address, phone, next of kin, hospital ID number, religion, insurance CO, place of employment, admitting physician, admitting diagnosis
  2. Six ways to chart
    • Source oriented (narrative)
    • POMR
    • Focus
    • Charting by exception
    • Computer assisted
    • Case mgmt system
  3. Advantages of source oriented charting (narrative)
    • Aspects of all steps of the nursing process
    • Baseline condition for each shift
    • Chronological order
  4. Disadvantages of source oriented charting (narrative)
    • Extensive charting time
    • Lengthy entries discouraging team members from reading all parts
    • Both abnormal and normal findings
  5. Source oriented charting focuses on
    Patient's disease
  6. Problem Oriented MR contains
    • Database
    • Problem list
    • Plan
    • Progress notes
    • Discharge Summary
  7. Two types of problem oriented MR
    SOAP and PIE
  8. SOAPIER
    • Subjective
    • Objective
    • Assessment
    • Plan
    • Implementation
    • Evaluation
    • Revision
  9. PIE
    • Problem
    • Intervention
    • Evaluation
  10. Advantages of POMR
    • Provides documentation of comprehensive care
    • Problem solving approach
    • Improves continuity of care
    • Easy to audit
    • Reinforces applicatino of the nursing process
    • Requires continual evaluation and revision of the plan of care
  11. Disadvantages
    • Loss of chronological charting
    • More difficult to track trends
    • Fragments data due to many flow sheets
  12. Focus charting is similar to
    POMR but changes problem (negative) to focus (positive)
  13. Focus charting is directed at a
    nursing diagnosis, patient problem, concern, sign, symptom, or event
  14. Three components of focus charting
    • Data
    • Action
    • Response
    • (sometimes, Evaluation)
  15. Advantages of focus charting
    • Compatible with use of nursing process
    • Shortens charting time
    • Focus not limited to patient problems or nursing diagnosis
  16. Disadvantages of focus charting
    • If database is not sufficient, patient problems may be missed
    • Does not adhere to chartingb with focus on nursing diagnoses and expected outcomes
  17. Charting by exception is based on
    All standards of practice are carried out and met with normal response unless otherwise documented
  18. Advantages of charting by exception
    • Highlights abnormal data and patient trends
    • Decreases narrative charting time
    • Eliminates duplication of charting
  19. Disadvantage of charting by exception
    • Requires development of detailed protocols and standards
    • Requires retraining staff
    • Nurses become used to not charting that important data are sometimes omitted
  20. Advantages of computer aided charting
    • Date and time automatic
    • Legible notes
    • Fast communication
    • Can reduce errors
  21. Disadvantages of computer aided charting
    • Sophisticated security system needed
    • Large upfront cost
    • Can take a long time to set up
    • Computer down time
  22. Guidelines for charting about a sign or symptom
    • Quality
    • Quantity
    • Chronology
    • Setting
    • Aggravating or alleviating factors
    • Associated manifestations
  23. Charting is organized by
    Nursing diagnosis or problem
  24. If you make an error while charting
    Write "error" above it and add the date and initials
  25. If you have a late entry
    Write the time of the entry, circle it, and write "late entry" and your initials about the time
  26. Who provides the guideline for required documentation
    American Nurses Association
  27. Difference between narrative and POMR
    The separation of notes on medical care and nursing care
  28. When MR is needed as evidence in court, it is the property of the
    patient
  29. Advantage of POMR when using interdisciplinary system is that
    All menbers of the team chart in a sequential order
  30. When charting the patient's condition and nursing care, the nurse records
    Patient statements and observed behaviors

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