Charting
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28 terms
Terms | Definitions |
|---|---|
 -These are organized into sections for easy use.-Each page is stamped with the client's name, room and bed number, and other identifying information. -Health team members record information on the forms for their departments. | The record (chart) has many forms |
| *Telling a story *All details to be included *Begin with date, time *Include -What you did and when -Whom you reported to -The client's response -Any results or problems | Narrative Charting |
| SOAP DAR PIE FAIR | Methods of Charting |
| Only health care team members involved in the client's care have access to confidential information | Access to the client's charter |
| Computer systems and some personal digital assistants collect, send, record, and store information | PDAs |
| -Assessment -Nursing diagnosis -Planning -Implementation -Evaluation | The care planning process has five steps: |
| (also known as nursing process) is the method nurses use to plan and deliver nursing care | The care planning process |
| Assessment involves collecting information about the client | Assessment |
| never ends | The assessment step |
| -You make many observations as you give care and talk to the client. -Objective data (signs) are seen heard, felt, or smelled. -Subjective data (symptoms) are things a client tells you about that you cannot observe through your senses | Support workers play a key role in assessment |
| -The RN uses assessment information to make a nursing diagnosis. -A nursing diagnosis describes a health problem that can be treated by nursing measures. -A client can have many nursing diagnoses. -They deal with the total person (physical, emotional, social, and spiritual needs). | Nursing diagnosis |
| -Planning involves setting priorities and goals. -The needs are arranged in order of importance. -Goals are then set -Nursing interventions are chosen after goals are set | Planning |
| is an action or measure taken by the nursing team to help the client reach a goal | a Nursing interventions |
| -Is a written guide about the client's care -Has the client's nursing diagnoses and goals -Has the measures or actions for each goal -Is a communication tool -Is used by nursing staff to see what care to give -Helps ensure that the nursing team members give the same care | The nursing care plan (care plan) |
| it is continually reviewed and revised, depending on the client's needs, condition, and progress | The care plan is not a finished document - |
| The implementation step is performing or carrying out nursing measures in the care plan. -Care is given during this step. | Implementation |
| from simple to complex | Nursing care ranges |
| Changes in nursing diagnoses result in changes in the care plan | New observations may change the nursing diagnoses. |
| -Each client's care -What measures and tasks need to be done -Which nursing tasks to do | The assignment sheet tells you about: |
| Talk to the nurse. Check the care plan and Kardex. | If an assignment is unclear: |
| The Care Plan in a Community Setting | -Case managers co-ordinate and manage client care. -Meetings take place in the client's home. -Family is very important to the assessment process, because serious illness greatly affects the family roles. |
| Community Planning | -Case manager establishes priorities, sets goals, and determines available resources. -Plan includes services provided by family members, outside professionals, and agencies. -Some clients choose to co-ordinate and manage their own care. |
| Community Implementation and Evaluation | -Unforeseen needs arise - support workers must be able to adapt to request and adjust the care to best meet the client's needs. -Evaluation is ongoing - case manager reviews care and services. |
| Evaluation | -This step involves measuring if the goals in the planning step were met. -Progress is evaluated. -Assessment information is used for this step. -Changes in nursing diagnoses, goals, and the care plan may result. |
| Support workers provide valuable information | towards this evaluation, which may result in changes being made to the care plan. |
| Support Worker Role | The nurse uses support worker observations for nursing diagnoses and planning. -In the implementation step, support workers perform nursing actions and measures outlined in the care plan. -Your observations are used for the evaluation step. |
| Observations | - an active process of sensing and assimilating information. |
| Developing Observation Skills | -Use senses: Sight, hearing, touch, smell -Listening to the client breathe, noticing flushed or pale skin, noticing red swollen ankles, smelling unusual odours from urine/bowel movement |
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