Nursing 151 Profession of Nursing

Any paper, electronic, information about a cient describing care or service to patient. Relied on for proof in legal situations. Reflects ongoing patient status, nursing process, care. Communication between disciplines and fellow workers.

- Assessment of the health status - Changes in function - S/S - Nursing actions, patients response - Advocacy undertaken - Visits by others - Date, Time, Signature and designation

- Factual - Accurate - Complete - Current - Organized - Compliant with standards

- Date/time - Signature - Sequence - Designation - Legible - Black or blue ink ONLY - Permanence - Accuracy - Terminology - Completeness - Correct Spelling - Concise - Legal prudence - Chart YOUR care ONLY - 24 hour clock - Approved abbreviations - No whiteout, one line cross out

Faliure to document: - Administered meds - Allergies - Client care - On correct record - Discontinued meds - Transcribe orders incorrectly

1) Narrative 2) Problem Oreiented Medical Records (POMR) or Health Care Records 3) Source Records 4) Charting by Exception 5) Critical Pathways or Care Plans

Documenation system KEY: Traditional, story like, specific patient condition and nursing care ADV: Flexible, easy, strongly conveys interventions and patient response DIS: Unstructured, repitition of info, time consuming

Problem Oriented Medical Records Documentation System KEY: Based on patient's reason for seeking care, emphasis on problem, cosists of database, problem list, plan of care, progress notes - SOAP (Subjective, Objective, Assessment, Evaluation) - PIE (Problem, Intervention, Evaluation) - DAR (Data, Action, Response) ADV: Focus on patient problem, easy info retrieval, clear interventions, reflects nursing process DIS: Time consuming, negative focus

Documentation System KEY: Separate sections of chart for each discipline ADV: Caregivers can locate specific records DIS: Same problem throughout

Documentation System KEY: Non- traditional, significant or abnormal findings only charted, all standards assumed met if not documented, unique flow sheets, standard care plans, and progress notes ADV: Evaluate and document findings consistently, eliminates repitition, concise DIS: Legality issues, patient/family perspective

Documentation System KEY: Identifies epected outcomes for eahc day of care/type focus on positive and negative outcomes

Aka Adverse event - Any event not part of routine care that results in injury or risks client injury - Must be reported

- Face to face - Tape recorded - Telephone and verbal (Not allowed as Nursing Student), would not advise to do this kind of reporting

- Confidential - Clear - Concise - Accurate - Facts - Logical sequence - Highlight important information - Avoid bias

Idea or mental image of a phenomena; building blocks to theory - Concrete - measureable, able to see - Abstract - immeasurable, independent of time, place (ex hope and power)