17 terms

Advantages & disadvantages of documentation formats

Exam 1
Advantages of narrative notes
Allow nurses to describe a condition, situation, or response in their own terms, as they understand it
Advantage of SOAP notes
-The location of the problem at the front of the chart alerts all caregivers.
-care is problem focused
-easy retrieval of information
-SOAP is consistent in the nursing process
Advantage of PIE (problem intervention evaluation)
-saves time, no formal care plan to update
-consistent in nursing process.
Advantage of Focus charting
-Ease of charting w/ DAR (data, action, response)
-emphasis on pt priorities
Advantage of Charting by exception
-Abnormal status can be given immediately
-flow sheet format shows overall trends in pt's condition
-guidelines provide specific but concise standard information regarding "normal" assessments & outcomes
-Documentation time is decreased because standard care is not written in narrative, timelier manner
-lower costs
Advantage of Case management model
-efficient use of time due to pt planned interventions
-increased probability that the pt will be discharged in a timely fashion
-care is goal focuses--> increases quality
-Promotes collaboration & teamwork
*works best w/ typical pt's w/ few individual needs
Disadvantages of Narrative notes
time consuming to read days & weeks of narrative notes to find a specific problem, its treatment and response
Disadvantages of SOAP notes
-level of ability & consistency of formats may vary
-problem focus may reduce pt' problemS to to solved
-maintaining a neat up to date problem list takes time to review
Disadvantages of PIE
No formal care plan so the nurse will have to read all nursing notes to determine problems, interventions & evaluations to see if they are actually effective.
Disadvantages of focus charting
Nurses have difficulty documenting the "result" portion, some write the problems resulting from assessment while others write the care of plan and nursing intervention
Disadvantages of charting by exception
Preventive & wellness promoting functions of nursing are not documented on this format.
the system requires predictable, defined pt outcomes which are more difficult to predict for some pts
Disadvantages of case management model
-less helpful for pt's w/ multiple dx's
-space to document is limited, too much writing causes it hard to read
-space for individualization is limited
The intervention slow sheet, nursing notes & critical path must all be reviewed to get a picture of a pt's condition.
Intervention, what did we do to help with that problem
Evaluation, how did what we do work for the pt
-incorporated into progress notes, no separate plan of care.
Each focus gets a different entry. focuses on care to pt & pt concerns.
DAR format
right pt record (pt name on top of form)
S: Subjective information related to the pt's problem, pain
O: Objective data, all the data that can be measured, where is the pain, admission, vitals (TPRBP)
A: Assessment, don't repeat info. From objective data, instead come up w/ a nursing dx w/ data, make a clinical assessment from it.
P: Patient, what are we going to do for this pt...teach, give meds (per order), etc. continue to monitor.
Flow sheet
V ^ are systolic over diastolic, points are pulse
-Read back information
-Don't use words like normal good or average, be precise "what would be a well documented statement."
-Document correctly, specific, re-read your note before you hand it in.
-Do not document something before you do it.