| Documentation is integral to this phase of nursing | Implementation phase |
| The five basic purposes for complete and accurate patient records | Documented Communication, Permanent Record for Accountability, Legal Record of Care, Teaching, Research and Data Collection |
| Five areas of patient needs proper charting must cover | Physical, Emotional Psychological, Social and Spiritual |
| EHR | Electronic Health Records |
| EMR | Electronic Medical Records |
| SBARR | Situation, Background, Assessment, Recmmendation, Read Back |
| DRG's | Diagnosis-Related Groups |
| people appointed to examine patient charts and health records to assess quality of care | Auditors |
| Appraisal by proffession coworker of equal status | Peer Review |
| ADPIE | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| DARE | Data, Action, Response and Evaluation, Education and Patient Teaching |
| POC | Point of Care |
| POMR | Problem-Oriented Medical Record |
| SOAPE | Subject, Objective, Assessment, Plan, Evaluation |
| SOAPIER | Subjective, Objective, Assessment, Planning, Intervention, Evaluation, Revision |
| ADPIE | Assessment, Diagnosis, Planning Intervention, Evaluation |
| APIE | Assessment, Problem, Intervention, Evaluation |
| MAR | Medication Administration Record |
| PHR | Personal Health Report |
| The three essential pieces to charting interventions | Type of intervention, Time of intervention and title and signature of person providing the care |
| Four provisions of patient charts | Concise, Accurate and Permanent Records of Past and Present Medical and Nursing Problems, Plans of Care, Care Given and Patient Response to Treatment |
| Officials appointed by various agencies to evaluate and institution's patient care to justify reimbursement by review of specific charting components for appropriateness and completion | Auditors |
| Appraisal by professional coworkers of equal status which reviews the manner in which a nurse conducts practice, education or research | Peer Review |
| An audit in health care which evaluates services provided and the results achieved compared to accepted standards | Quality Assurance, Assessment and Improvement |
| The entity which owns health care records | The physician or facility |
| Three entities with legal access to patient records | The facility, Lawyers and the patient |
| EHR vs EMR | EHR allows exchage of data between multiple facilities while EMR only allows access to the facility |
| An extension of EHR that allows patients to input their information into the database | PHR |
| Cons of PHR | How the information will be stored, who will store the information and at what cost |
| Basic Rules for Documentation | Provide Correct Information, Avoid Generalized Phrases, Be Objective, Be Timely, Specific, Accurate and Complete, Chart AFTER the care is provided, Chart ordered care as given or explain deviation, Chart ASAP, Chart facts only, Chart only care you have given, Chart only as observed without opinions or speculation, Fill all spaces, follow institution policy, correct grammar and punctuation is key, correct any errors per institution policy, if order is questioned seek clarification, note patient response to treatment, Sign charting per institution policy, use quotes as appropriate, Use only abbreviation approved by facility, black non-erasable ink only, note any late entries as late before proceeding with notations, write legibly |
| Type of care documentation should indicate was given | Individualized, Goal Oriented and Accurate |
| Charting with emphasis on specific sections of information given through narrative. Includes Objective and Subjective Data, whether anyone was consulted , care and treatment provided and patients response to said treatment | Traditional(Block) Charting |
| Documentation organized to scientific problem solving method. Comprised of database, problem list, care plan and progress notes | Problem Oriented Medical Records |
| Documentation acronymns associated with POMR format | SOAPIER and SOAPE |
| Documentation Format based upon the nursing process and the concept of focusing on patient needs rather than medical diagnosis | Focus Charting Format |
| Documentation Acronym associated with Focus Charting Format | DARE |
| Documentation format in which the nurse charts a complete assessment at the beginning of the shift and only takes further notes and changes occur | Chart by Exception |
| Documentation acronym associated with chart by exception | APIE |
| A cumulative care file used for quick reference to pertinent patient information | Kardex or Rand |
| A Form used to report any event not consistent with routine care | Incident Report |
| Charting system which rates patients for severity of illness(1 high, 5 low). Allows determination of proper staffing patterns based upon overall needs of patients | Acuity Charting |
| Benefits of Discharge Charting | Allows Patients access to pertinent information regarding their continued care and helps to reinforce patient teachings |
| Documentation tools which allow staff from all disciplines to develop a standard integrated care plan for patients of specific care type | Clinical(Critical) Pathways |
