It's in the Chart
Single line strike-through charting date, time, initials/signature
Correcting an error
Psychosocial Development: Id, Ego, Superego
Sigmund Freud
Allowing a toddler to feed and dress themselves, fostering autonomy follows theory of…
Autonomy vs. Shame and Doubt
Normal changes associated with aging
Physical decline/ Benign senescence
Matriarchal family structure
African American
Charting is expensive, requires passwords, and safeguarding confidentiality, but is thorough and timely
Electronic Documentation
Psychosocial Development: Crisis and Task
Erik Erikson
Teenage years
Identity vs. Role Confusion
Weaker respiratory muscles and decreased cilia predispose elderly to…..
Respiratory diminishing/failure
Only meat drained of blood may be eaten; may receive an organ if it is cleansed with non-blood solution but cannot donate an organ; do not receive blood
Jehovah’s Witnesses
The property of the facility, not the patient
The Chart
Cognitive Development
Jean Piaget
Risky behavior, stress related illness, early disease screens
Young Adults
Erikson’s stage for a 75 year old who recalls to the nurse his good and rewarding life
Ego Integrity vs. Despair
Anyone can perform a baptism if a priest is not available in an emergency
Roman Catholic
This charting includes “Subjective, Objective, Assessment, and Plan”
SOAP Charting
Moral Development
Lawrence Kohlberg
Dependent children at home and dependent older adults needing care
“Sandwich Generation”
Signs and symptoms of 82 year old with neglected hygiene, weight loss, stops going to church and book club
Depression
Two religions that share the first five books of the Old Testament, and thus many common dietary laws
Judaism and Christianity
Only ‘abnormals’ and care above or beyond the standard, are documented
Charting by exception
Autonomy vs. Shame and Doubt; Identity vs. Role Confusion
Infancy and early childhood stages of Ericson’s Psychosocial Development
Fifty-two year old mother, librarian, Girl Scout Leader, read for literacy volunteer
Adulthood: Generativity vs. Self-absorption
Signs and symptoms: 88 year old, weight loss, unexplained bruises on arms, avoiding eye contact
Elder Abuse
Women of this religion must not be touched or seen by a man who it not a family member; keep covered at all times
Muslim