Podcast
Questions and Answers
Basic Two-Part Statements
Basic Two-Part Statements
Problem and Etiology
statement of the client’s response (NANDA Label)
statement of the client’s response (NANDA Label)
Problem
factors contributing to or probable causes of the responses.
factors contributing to or probable causes of the responses.
Etiology
Basic Three-Part Statements
Basic Three-Part Statements
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defining characteristics manifested by the client.
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
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
regulations that maintain privacy & confidentiality of protected health information
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admissions department – admission’s sheet
admissions department – admission’s sheet
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database, problem list, plan of care, progress notes
database, problem list, plan of care, progress notes
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SOAP
SOAP
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SOAPIER
SOAPIER
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PIE
PIE
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FDAR
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
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
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
Graphic record Intake & output record Medication administration record Skin assessment record Progress notes Nursing discharge/referral summaries
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POMR
POMR
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HIPAA
HIPAA
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