17 terms

methods of recording

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Terms in this set (...)

narrative reports
story telling
Problem-oriented medical record
database, problem list, care plan, and progress notes
SOAP
subjective, obejective, assessment, plan
SOAPIE
subjective, objective, assessment, plan, intervention, evaluation
SBAR
situation, background, assessment, recommendation
PIE
problem, intervention, and evaulation
Focus Charting
involves the use of data, action, and response (DAR)
source record
separate section for each discipline
charting by exception
focuses on deviations from the established norm or abnormal findings; highlights trends or changes
case management
incorporates a multidisciplinary approach to documenting care
critical pathways
multidisciplinary care plans that include client problems, key interventions, and expected outcome.
admission nursing history forms
provide baseline data to compare with changes in the clients condition.
flow sheets
data entry of assessment such as vital signs, hygiene measures, ambulation, restraint checks
kardex
has activity, treatment, nursing care plan sections that organize information for quick references
acuity records
determine the hours of care and staff required for a given group of clients.
standardized care plan
preprinted, established guidelines used to care for the client
discharge summary forms
emphasize previous learing by the client and the care that should be continued.