Mrs. Yeager's Homepage

Nursing 205 Homepage

Nursing 215 Homepage

Nursing 230 Homepage

READ CAREFULLY:

1. Taylor, Lillis, & LeMone, Chapter 20 (pp. 317-342)
2. Class lecture notes off the Internet

TERMS TO KNOW:

1. Change-of-shift report
   1. communication method used by nurses completing care for a patient to transmit patient information to nurses about to assume responsiblity for continuing care; may be exhanged verbally in a meeting or audiotaped
2. Charting by exception
   1. shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrrative notes
3. Patient record
   1. a compliation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient
4. Critical pathways/collaborative pathways
   1. case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay
5. Discharge summary
   1. description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals
6. Documentation
   1. written, legal record of all pertinent interventions with the patient - assessments, diagnoses, plans, interventions, and evaluations
7. Flow sheet
   1. graphic record of abbreviated aspects of patient's conditions (e.g., vital signs, routine aspects of care)
8. Focus charting
   1. a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format
9. Graphic sheet
   1. a form used to record specific patient variables
10. Medication record
    1. record documenting all medications administered to the patient, the nurse administering the drugs, and sometimes the reason the drug was administered and its effectiveness
11. Narrative notes
    1. descriptive record of the patient's condition; includes patient's response to interventions by health professionals and patient's progress toward goal achievement
12. Nursing care conference
    1. formal meeting of nurses to discuss some aspect of a patient's care
13. Nursing care rounds
    1. procedure in which a group of nurses visit patients individually at the bedside to gather information that helps to plan and evaluate nursing care
14. PIE charting
    1. a documentation system that is unique in that it does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P), intervention (I), evaluation (E) format, and evaluated each shift
15. Problem-oriented record
    1. documentation system organized according to the person's specific health problems; includes a data base, problem list, plan of care, and progress notes
16. Progress notes
    1. any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
17. Referral
    1. process of sending or guiding someone to another source for assistance
18. Report
    1. oral, written, or computer-based communication of patient data with the purpose of informing others
19. SOAP format
    1. method of charting narrative progress notes; organizes data according to the subjective information (S), objective information (O), assessment (A), and plan (P)
20. Source-oriented record
    1. documentation system in which each healthcare group records data on its own separate form
21. Variance charting
    1. documentation method in case managment that records unexpected events, the cause for the event, actions taken in reponse to the event, and discharge planning when appropriate

LEARNING ACTIVITIES:

1. Lecture
2. Discussion
3. Read the following PRIOR to class:
   1. Taylor, Lillis, & LeMone, Chapter 20 (pp. 317-342)
   2. Class lecture notes off the Internet
4. Nursing Process Exercise

STUDY QUESTIONS TO REVIEW FOR TEST:

1. How to modify a care plan.
2. Definition and parts of a "source-oriented" record and what is located in each part.
3. SOAP, SOAPIER charting and what would be charted in each area.
4. Probem-oriented charting and what would be charted in each area.
5. Elements of effective charting.
6. Flowsheets, KARDEX, consultation report, and diagnostic report.
7. Definition and parts of a "problem-oriented" record and what is located in each part.
8. Focus charting and charting by exception and what would be charted in each area.

Return to Top