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  1. why do we document in a chart?
    • communication
    • auditing agents
    • reimbursements
    • research
    • education
    • legal reasons
  2. Documentation Systems
    • Source-oriented record
    • problem-oriented medical record
    • PIE
    • Focus Charting
    • computerized documentation
    • case management
  3. Source-oriented Record
    • Traditional client record.
    • Each department makes notations in a separate section or sections of the client's chart
  4. Problem Oriented Medical Record

    Emphasis on the patient’s problems.

  5. POMR
    • database
    • problem list
    • plan of care
    • progress notes
  6. SOAP(IE)
    • subjective data
    • objective data
    • assessment
    • plan
    • (Intervention
    • Evaluation)
  7. Charting by Exception (CBE)
    a documentation system in which only significant findings or exceptions to norms are recorded
  8. Flow Sheet
    • A record of the progress of specific or specialized data such as :
    • vital signs,
    • fluid balance
    • routine medications
  9. PIE
    an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
  10. Telephone reports
    • Provide clear, concise, accurate information
    • Document: when, who made call, who was called, to whom info was given, what info was given, what info was received
  11. Incidence or occurrence report
    • Incident not consistent with routine care & safety issues
    • Record what actually happened
    • Do not record in medical record that incident report was filled out
    • Used in quality improvement programs to monitor trends
  12. Factual
    • Descriptive, objective data about what you
    • see, hear, feel, or smell
    • Result of direct observation and measurement
    • NO seems, appears, apparently
    • Subjective data – document patient’s exact words in quotation mark
  13. Narrative
    • Paragraph form, long, time consuming
    • Information can be organized in any logical manner
    • Reflect progress toward goals
  14. Best responses always give client more____
    Time to talk
  15. Therapeutic communication benefits client's health status in 3 ways
    Gives information, controls pain, investigates feelings
  16. Phases of the Helping Relationship
    • Preinteraction phase
    • Introductory phase
    • Working phase
    • Termination phase
  17. Preinteraction phase of the Helping Relationship
    • reviews pt information
    • considers areas of concern
    • develops plan for interaction
  18. Introductory Phase of the Helping Relationship
    • Open the relationship
    • Clarify problem
    • Structure and formulate contract
  19. Working Phase of the Helping Relationship
    • Explore and understand thoughts and feelings associated w/problem
    • Facilitate and take action
  20. Termination Phase of Helping Relationship
    • Accept feelings of loss
    • End relationship without feelings of anxiety or dependence
  21. Components of the Communication Process (4)
    • Sender
    • Channel
    • Receiver
    • Feedback
  22. Domains of Learning (3)
    • Cognitive knowledge
    • Affective disposition (emotions)
    • Psychomotor (skills)
  23. Restating
    • The main idea of what the client has said is repeated
    • Lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary
  24. Reflecting
    Questions and feelings are referred back to the client so that they may be recognized and accepted
  25. Using _____ allows the client to take _______ of the discussion if he or she desires
    Silence, Control
  26. When the nurse allows the client to select the topic, it is known as
    Giving broad openings
  27. What is the first goal of therapeutic communication, and how do we monitor this?
    Safety first! Know if things are escalating through body language: they're walking fast, not listing.
  28. SOLER
    • Sit facing the client
    • Observe your open posture
    • Lean forward toward the client
    • Establish Eye contact
    • Relax.
Card Set:
2011-09-25 22:47:56

Nursing Documentation
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