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What word to use?
Observations
ANA Nursing Documentation Principles
What goes where?
What? Why? Who?
100
RNs, CPTs,MDs, PTs, RTs, SW...
Who are some of the members of the health care team?
100
Vital signs, lab results, patient behavior.
What is Objective DATA?
100
Your nursing note is descriptive yet to the point.
What is CLEAR AND CONCISE nursing documentation?
100
"I feel a little short of breath"
What is Subjective DATA?
100
In your nursing note, this is written first....
What is date and time?
200
This independent, not-for-profit organization accredits and certifies more than 19,000 health care organizations and programs in the United States.
What is Joint Commission?
200
A patient states, "I can't catch my breath" or rates their pain as a 5 on a scale from 0 to 10.
What is Subjective DATA?
200
Your nursing note is written in the D.A.R. format shortly after working with your patient.
What is COMPLETE AND TIMELY nursing documentation?
200
Patient positioned in high Fowler's position.
What is a nursing ACTION/intervention?
200
This information describes the "situation" (not Mike but the patient situation)...
What are Subjective and Objective DATA?
300
When a suit it filed, these organizations represent patients and organizations.
What are legal and legislative bodies?
300
Repositioning a patient, administering oxygen or medication per MD orders, discharge teaching...
What are nursing ACTIONs/interventions?
300
Your nursing note includes a wound measurement and description with a signature and credentials at the end.
What is an accurate and authenticated nursing note?
300
Patient's respiratory rate has decreased to 16 and effort is now unlabored.
What is a patient RESPONSE/outcome?
300
In your nursing note, this information informs the health care team what was done for the patient...
What nursing ACTIONs/interventions were done for the patient?