chapter 12
includes all the data the nurse can verify
objective data
the provision of required nursing care to accomplish established client goals
implementation
medical record
Where data are input to the computer
Computer-assisted charting
What time is 1400?
2pm
What are the 4 steps of the nursing process?
Data collection
Planning
Implementation
Evaluation
involves assisting the RN in the development of the nursing diagnosis, goals, and interventions for a client's plan of care while maintaining client safety.
Planning
Organized by a “source” or author of the documentation entry
Source-oriented charting
as a legal record, the medical records contents are..
confidential
What time is 0000?
12am
Based on the client's opinion
subjective data
data that is reported immediately
emergency data
Focuses on the problems the patient experiences as a result of being ill
Problem-oriented Medical Record charting
What does SOAPIE stand for?
Subjective information
Objective information
Assessment
Plan
Implementation
Evaluation
What time is 2300?
11pm
systematic gathering and review of information about the client, which is communicated to the appropriate members of the health team
data collection
Important step in thinking critically
verifying information (validating)
Centers on the patient from a positive perspective
Focus charting
computerized comprehensive record of the patient's history and care across all facilities and admissions
electronic health record (EHR)
What time is 1730?
5:30pm
compares the actual outcomes of nursing care with the expected outcomes
evaluation
identify specifically what the nurse will do to assist the client to reach desired client outcomes.
interventions
Focuses on deviations from predefined norms, using preset protocols and standards of care.
Charting by exception
also called standard procedures
protocols
What time is 1845?
6:45pm