Nurs 207 - Communication/Documentation Flashcards
Purposes of Documentation
Faciliate continuity of care Track outcomes Communication to team members Prove that health care was undertaken Act as evidence in the court of law Confirms suitable professional practice
If you don’t document it…
you didn’t do it!
True or False. Documentation and reporting practices differ among institutions and jurisdictions.
True!
Documentation must be…
accurate and comprehensive and must reflect standards of nursing practice
What influences documentation?
ethical, legal, medical, and agency guidelines
List the Guidelines for quality documentation and reporting
Factual
Accurate
Complete
Current
Organized
Compliant with Standards
Types of Documentation
Formal
Informal
Examples of Informal Documentation Methods
Worksheets
Communication Sheets
Shift Reports
Examples of Formal Documentation Methods
Kardex and admission databases Care plans Progress Notes Flow sheets Care checklists Transfer records
Progress Notes
Narrative
Problem Orientated
- SOAP
- SOAPIE
- PIE
- Focus Charting (DAR)
SOAP
Subjective data
Objective data
Assessment
Plan
SOAPIE
Subjective data Objective data Assessment Plan Intervention Evaluation
PIE
Problem
Intervention
Evaluation
DAR
Data
Action
Response
