chapter 12
Chapter 12 continued
chapter 7
chapter 7 continued
Military time
100

includes all the data the nurse can verify

objective data

100

the provision of required nursing care to accomplish established client goals

implementation

100
sometimes referred to as a chart

medical record

100

Where data are input to the computer

Computer-assisted charting

100

What time is 1400?

2pm

200

What are the 4 steps of the nursing process?

Data collection

Planning

Implementation

Evaluation

200

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

200

Organized by a “source” or author of the documentation entry

Source-oriented charting

200

as a legal record, the medical records contents are..

confidential 

200

What time is 0000?

12am

300

Based on the client's opinion

subjective data

300

data that is reported immediately

emergency data

300

Focuses on the problems the patient experiences as a result of being ill

Problem-oriented Medical Record charting

300

What does SOAPIE stand for?

Subjective information

Objective information

Assessment

Plan

Implementation

Evaluation

300

What time is 2300?

11pm

400

systematic gathering and review of information about the client, which is communicated to the appropriate members of the health team

data collection

400

Important step in thinking critically

verifying information (validating)

400

Centers on the patient from a positive perspective

Focus charting

400

computerized comprehensive record of the patient's history and care across all facilities and admissions

electronic health record (EHR)

400

What time is 1730?

5:30pm

500

compares the actual outcomes of nursing care with the expected outcomes

evaluation

500

identify specifically what the nurse will do to assist the client to reach desired client outcomes. 

interventions

500

Focuses on deviations from predefined norms, using preset protocols and standards of care.

Charting by exception

500

also called standard procedures

protocols

500

What time is 1845?

6:45pm