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why do we document in a chart?
- communication
- auditing agents
- reimbursements
- research
- education
- legal reasons
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Documentation Systems
- Source-oriented record
- problem-oriented medical record
- PIE
- Focus Charting
- computerized documentation
- case management
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Source-oriented Record
- Traditional client record.
- Each department makes notations in a separate section or sections of the client's chart
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Problem Oriented Medical Record
Emphasis on the patient’s problems.
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POMR
- database
- problem list
- plan of care
- progress notes
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SOAP(IE)
- subjective data
- objective data
- assessment
- plan
- (Intervention
- Evaluation)
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Charting by Exception (CBE)
a documentation system in which only significant findings or exceptions to norms are recorded
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Flow Sheet
- A record of the progress of specific or specialized data such as :
- vital signs,
- fluid balance
- routine medications
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PIE
an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
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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
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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
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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
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Narrative
- Paragraph form, long, time consuming
- Information can be organized in any logical manner
- Reflect progress toward goals
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Best responses always give client more____
Time to talk
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Therapeutic communication benefits client's health status in 3 ways
Gives information, controls pain, investigates feelings
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Phases of the Helping Relationship
- Preinteraction phase
- Introductory phase
- Working phase
- Termination phase
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Preinteraction phase of the Helping Relationship
- reviews pt information
- considers areas of concern
- develops plan for interaction
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Introductory Phase of the Helping Relationship
- Open the relationship
- Clarify problem
- Structure and formulate contract
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Working Phase of the Helping Relationship
- Explore and understand thoughts and feelings associated w/problem
- Facilitate and take action
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Termination Phase of Helping Relationship
- Accept feelings of loss
- End relationship without feelings of anxiety or dependence
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Components of the Communication Process (4)
- Sender
- Channel
- Receiver
- Feedback
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Domains of Learning (3)
- Cognitive knowledge
- Affective disposition (emotions)
- Psychomotor (skills)
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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
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Reflecting
Questions and feelings are referred back to the client so that they may be recognized and accepted
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Using _____ allows the client to take _______ of the discussion if he or she desires
Silence, Control
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When the nurse allows the client to select the topic, it is known as
Giving broad openings
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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.
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SOLER
- Sit facing the client
- Observe your open posture
- Lean forward toward the client
- Establish Eye contact
- Relax.
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