Term
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Definition
| Narrative; each department has a separate section for charting. Nurse must look in multiple sections to know what is going on with the patient. |
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Term
Problem-Oriented Charting
Definition
Advantages/Disadvantages |
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Definition
POR or POMR (Problem-oriented medical record); data arranged according to the problems the client has.
*Adv:Encourages collaboration and problem list is in front of chart so it is easier to track problem status.
*Disadv: Constant vigilance to maintain up-to-date problem list; inefficient bc things that apply to more than one problem must be repeated. |
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Term
POR/POMR
4 basic componenets |
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Definition
Database
Problem List
Plan of Care
Progress Notes |
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Term
Progress Notes (contained in POMR)
Format |
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Definition
SOAP
Subjective Data
Objective Data
Assessment
Plan |
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Term
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Definition
Subjective
Objective
Assessment
Plan
Interventions
Evaluation
Revision |
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Term
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Definition
Assessment - combines subjective and objective
Plan
Inverventions
Evaluation
Revision |
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Term
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Definition
Uses a client care assessment flow sheet and progress notes.
Groups info into 3 categories:
Problems - Pain? Nutrition? Elimination?
Interventions - What did I do to address the problem?
Evaluation - What happened? Did it help? Did it make it worse? |
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Term
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Definition
Client/client concerns and strengths = focus of care.
3 columns for recording:
Date and Time
Focus - condition, nursing diagnosis, behavior, sign
Progress Notes - organized into DAR format |
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Term
| DAR format of Focus Charting |
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Definition
Data - facts, assessments
Action - plan and what you did
Response- how did the patient fare? Evaluation |
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Term
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Definition
Charting by Exception- only abnormal or significant finding or exceptions to norms are recorded. Uses:
Flow Sheets
Standard of Nursing Care - according to agency's printed standards
Bedside Access to Chart Forms - allows immediate recording
Can chart WDL (within defined limits) except...
Can fill in blanks with N/A |
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Term
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Definition
| Electronic Health Record - integrates all pertinent client info into one record. |
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