Comprehensive Nursing Care Chapter 14 – Flashcards
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APIE
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Charting method; acronym for assessment, problem, intervention, and evaluation; based on the nursing process; consists mainly of assessment flow sheets and progress notes.
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Charting
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Recording; documenting; process of making an entry on a client's record.
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Charting By Exception
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A documentation system in which only significant findings or exceptions to norms are recorded; incorporates (1) unique flow sheets that highlight significant findings and define assessments parameters and findings, (2) documentation by reference to the agency's printed standards of nursing practice, and (3) documentation forms at the bedside.
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Clinical Record
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Chart; client records; formal, legal document that provides evidence of a client's care.
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Confer
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To consult another person for advice, information, ideas, or instructions.
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CORE
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A documentation system that focuses on the nursing process and consists of a database, plans of care, flow sheets, process notes, and discharge summary.
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DAR
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(D)diagnosis, (A) action, and (R) response; means of organizing progress notes into data.
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Database
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Baseline data; information about a client gathering from many sources; a reference point to assess changes in a client's condition.
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Discussion
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Informal conversation between two or more healthcare personnel to identify a problem or develop strategies to solve a problem.
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Documenting
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Process of making an entry on a client record.
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FACTS
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System of documentation that focuses on four elements: flow sheets that are individualized, assessment sheet that is standardized with baseline parameters, concise integrated progress notes and flow sheets that are used to document the client's condition and response, and timely entries that are recorded after care is given.
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Flow Sheets
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Abbreviated progress notes that enable nurses to record data quickly and concisely and provide an easy-to-read record of a client's condition over time.
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Focus Charting
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A type of record intended to make the client, along with client concerns and strengths, the focus of care.
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Incident
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Any unexpected event.
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Kardex
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A widely used, concise method of organizing and recording data about a client.
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Medication Administration Records
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Record of the date of the medication ordered, the expiration date, the medication name and dose, the frequency of administration and route, and the nurses signature.
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Nursing Care Conference
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Meeting of a group of nurses to discuss possible solutions to client problems.
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Nursing Rounds
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Procedures in which a group of nurses visits selected clients at each client's bedside.
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Objective Data
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Signs that are detectable by an observer or can be tested against an acceptable standard.
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PIE
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Charting method; stand for Problem, Intervention, and Evaluation; based on the nursing process; consists mainly of assessment flow sheets and progress notes.
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Problem-Oriented Medical Record
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Arrangement of data according to individual problems the client has rather than by the source of the information; also called problem-oriented recording (POR).
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Record
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A written or computer-based collection of data.
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Report
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A means of conveying information about changes in a client's condition promptly.
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SBAR
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(Situation Background, Assessment, and Recommendation) A system of standardized communication technique.
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SOAP
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An acronym for Subjective data, Objective data, Assessment and Planning.
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Source-Oriented Record
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A record in which information about a particular problem is documented under different sources.
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Subjective Data
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Symptoms, facts, perceptions, or sensations apparent only to the person affected.
