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17 Cards in this Set
- Front
- Back
Written collection of information about the clients health, the care provided by the health care provider & the clients progress
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Medical Record
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hard copy paper form of clients medical record
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chart
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this gives patients basic information or demographics...name address, DOB, etc
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Fact sheet
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written chronological account of patients illnesses progress & treatments
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permanent account
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central communication is
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sharing information
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this makes you keep up to agency standard, continuous quality improvement, or totally quality improvement
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Quality assurance
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this type of record contains separate forms from all providers Dr, nurse, PT, OT, dietary etc. can be bad because all the info is scattered
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Source oriented record
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This type of record is organized by the clients health problems
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problem oriented record
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This method of charting generally used in source oriented records. it involves writing info about the client in chronological order, remembles a journal
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Narrative
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Soap charting is used in problem oriented record. The S.O.A.P. stands for
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Subjective
Objective Analysis of Data Plan of care |
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This form of charting is a modied form of soap charting...uses a more positive word instead of problem...
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Focus charting
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What does PIE charting mean?
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Problem
Intervention Evaluation |
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in this form of charting nurses only chart abnormal finding
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charting by exception
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this is a reference of current information about the client care, changes constantly
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nursing kardax
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this is marked with initials or a check mark stating the nurse did something...often used for ADLs
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check lists
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visiting with clients on an individual basis or as a group HIPPA can become an issue
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client rounds
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when taking orders from a physician on the telephone what steps should be taken to insure that the correct order is taken
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have two nurses on the phone, clarify & verify the information
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