Documentation PPT (& documentation systems)
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What parts of documenting is important regarding legal issues? (3)
Date & time of entry.
When should you write a progress (narrative) note? (4)
- 1) admission, transfer, discharge
- 2) procedure is performed
- 3) post-surgery
- 4) contacting physician about change in PT status
When is the only time you should access Pt info.?
On a NEED TO KNOW basis.
What is an SOR?
- Ad: Easily chartable, easy to read specific info.
- Dis: Tracking problems; may decrease comm. btwn providers.
What format does it use?
- Problem-Oriented Medical Records
- Uses SOAP format.
- Ad: Easy tracking of problem list.
- Dis: Unfamiliar doc. system to providers; extra work to maintain problem list.
SOAP charting w/ POMR.
What is SOAP?
Give description of acronym.
- S: subjective data
- O: objective data
- A: assessment: conclusions & interpretation of sub. and obj. data.
- P: plan. Plan of Care designed to solve problem.
What is PIE?
- Problem, Intervention, Evaluation.
- Uses: progress notes, flow sheets
- Ad: NO care plan needed; maintenance of care
Dis: tracking problems is difficult.
What is Focus Charting?
What notes are used (1)? Organized into DAR. What is DAR?
Focuses on client's CONCERNS & STRENGTHS.
- D: (data) assessment & nursing observations.
- A: (action) planning
- R: (response) evaluation
Ad: HOLISTIC Pt perspective.
What is the most commonly used doc. system?
What does it use for assessments (2)?
CBE: Charting By Exception.
Uses flow sheets & graphic charts.
Which doc. system is used to report Pt care?
What other "reports" is it used for? (5)
SBAR (situation, background, assessment, recommendation)
- 1) change of shift reports
- 2) telephone reports
- 3) xfer & discharge reports
- 4) incident reports (not in Pt MR)
- 5) reports to family members
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