Validating and Documenting

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

Problem, Etiology, Signs and symptoms Signup and view all the answers

defining characteristics manifested by the client.

Signs and symptoms Signup and view all the answers

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

ANA Code of Ethics (2001) Signup and view all the answers

regulations that maintain privacy & confidentiality of protected health information

Health Insurance Portability & Accountability Act of 1996 (HIPAA) Signup and view all the answers

admissions department – admission’s sheet

SOURCE-ORIENTED RECORD Signup and view all the answers

database, problem list, plan of care, progress notes

PROBLEM-ORIENTED MEDICAL RECORD (POMR) Signup and view all the answers

SOAP

Subjective Objective Assessment Plan Signup and view all the answers

SOAPIER

(SOAP+ Interventions Evaluation Revisions) Signup and view all the answers

PIE

(Problem Interventions Evaluation) Signup and view all the answers

FDAR

FOCUS Charting Signup and view all the answers

 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

FOCUS Charting (FDAR) Signup and view all the answers

Widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals

KARDEX Signup and view all the answers

 Graphic record  Intake & output record  Medication administration record  Skin assessment record  Progress notes  Nursing discharge/referral summaries

FLOW SHEETS Signup and view all the answers

POMR

PROBLEM-ORIENTED MEDICAL RECORD Signup and view all the answers

HIPAA

Health Insurance Portability & Accountability Act of 1996 Signup and view all the answers