Questions and Answers
Basic Two-Part Statements
Problem and Etiology
statement of the client’s response (NANDA Label)
Problem
factors contributing to or probable causes of the responses.
Etiology
Basic Three-Part Statements
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defining characteristics manifested by the client.
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States that the nurse has a duty to maintain confidentiality of all patient information & that client’s record is legally protected as a private record of the client’s care
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regulations that maintain privacy & confidentiality of protected health information
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admissions department – admission’s sheet
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database, problem list, plan of care, progress notes
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SOAP
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SOAPIER
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PIE
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FDAR
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Intended to make the client & client concerns and strengths the focus of care Includes date, time, focus & progress notes Progress notes are organized as Data Action Response
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Widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals
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Graphic record Intake & output record Medication administration record Skin assessment record Progress notes Nursing discharge/referral summaries
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POMR
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HIPAA
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