Nursing: Docuumentations Ch. 6 of Foundations in Nursing
Terms
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- What is POMR?
- Problem oriented medical record.(problem solving method) Uses accumalated database to identify and prioritize the health problems on the master medical and problem list.
- What is PIE?
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P= Plan: plan of care to be given or action taken.
I= Intervention: specific care given or action. - What is FOCUS?
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Nursing processs and patient's needs rather than medical terms. DARE
D= Data: subjective (feelings)& objective data (vital signs)
A= Action: planning and implemmenting
R= Resonse of the patient.
E= Education-patient teaching - Documentaion is what part of teh nursing process?
- Implementation
- Patient health care records are:
- concise, legal records of all care given and responses
- What is the chart health care record?
- It is a legal document used to meet the many demands of the health, accreditation, medical insurance, and legal systems.
- What is essential in documentation?
- Evaluation of patient care. It is essential to chart interventions, the time care was rendered, and the care providers signature.
- What are the 5 purposes of patient records?
- 1. written communication 2. permanent record for accountability 3. legal record of care 4. teaching and 5 is research and data collection.
- What is the permanent written record good for?
- Used by government agencies to evaluate the institution's patient care and to utmost prove that care was given for cost reimbursement. Institutions are reimbursed by insurance companies or gov. programs ONLY for the patient care documented.
- What is traditional charting?
- It is divided into specific sections. Emphasis is placed on the admission sheet, doctor's orders, progress notes, history and physical examination, care paln and nursing notes, etc.
- What is the difference betwen narrative charting and POMR?
- They both include subjective and objective data, implementation (care and treatment provided), and evaluation (patients responce to treatment). Narrative notes are very descriptive whereas POMR uses an outline style.
- What is R in SOAPIER?
- R= revision; includdes the changes that may be made to the original plan of care.
- What is A in SOAP?
- A= assessment; potential diagnosis of the cause of the patient's problem or need.
- Focus charting format uses what acronym?
- DARE: data, action, care, education. This format focuses on patient's needs rather than medical diagnosis and problems.
- What is A in DARE?
- Action: combination of implementing and planning. What is the plan of care that will be given or action to be taken?
- What is R in DARE?
- R= Response; evaluation of effectiveness.