Mikes NCLEX Chapter 7

Focus charting

PIE charting

Case management system charting

Problem-oriented medical record (POMR) charting

requires development of detailed protocols and standards.

does not highlight abnormal data.

increases duplication of charting.

increases narrative charting time.

"ambulated 2X during shift, 50 ft with assistance of one. Pre-activity vs: 85, 18, 110/70; post-activity vs: 95, 22, 120/76."

"received 250 mL tube feeding during shift, tolerated well."

"ambulated to nurses station and back, tol well."

"aggressive and combative during a.m care"

security information is guaranteed with the computer system

others can see what is being input as the nurse works with the charting screens

it is cost effective because it saves nursing time compared with writing out notes

computer are al time ways up, running, and available

uninterrupted access to patient medical records.

automatic routing to the appropriate clinical areas for action.

all associated clinic and hospital systems' medical records being integrated.

free-text narrative data being integrated easily for data mapping.

all charting is done on flow sheets

it keeps all relevant data in one place

nurses have to chart only on flow sheets

not as many flow sheets are used

Include the names of all visitors with the time of the visit

sign your full name, date, and time on each sheet

check that you are on the right chart or screen and on the right date

use acronyms you are familiar with to shorten notes

if it was not charted, it was not done

unless otherwise documented, all standards have been met

patient care is charted chronologically

a SOAPIER format note must be made each shift

the court

the patient

the patient's lawyer

the health care agency

activities planned for a later date

goals for the medical treatment and evaluation

the interventions performed and the patient's responses

clinical data measurements

patient statements and behaviors that are observed

a focus on the patient's problems

a specific order of forms in the chart

patient identification stamped on each form

the separation of notes on medical care and nursing care

they have a right to a copy of their record after

the physician must write an order for the release of the record

only health care staff have the right to read the record

the patient and the family have a right to read the record

Problem-oriented medical record (POMR) charting

Charting by exception

Source-oriented charting

Focus charting

Plan of care

Serial record of 24-hour intake and output (I&O)

Results of laboratory tests

Wound dressing changes

allow her to use your password, just this once.

sit with her and access the data together.

inform her to contact the IT Department to obtain a new password.

tell her you're busy, and to ask someone else.

indicates the client's baseline condition for each shift.

shortens charting time by using flow sheets.

highlights abnormal data.

adheres to charting with the focus on expected outcomes.

sentences are necessary in charting.

notes may focus on the future.

chart any new change in patient behavior.

during charting, write "patient" when the patient is the subject of the sentence.

not include care given by nursing assistants.

reveal evidence of patient care.

act as a guide for reimbursement.

incorporate the nursing process.

retrievable for 20 years.

available to family members.

a legal record.

the property of the patient.