Validating and Documenting

Basic Two-Part Statements

statement of the client’s response (NANDA Label)

factors contributing to or probable causes of the responses.

Basic Three-Part Statements

defining characteristics manifested by the client.

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

regulations that maintain privacy & confidentiality of protected health information

admissions department – admission’s sheet

database, problem list, plan of care, progress notes

SOAP

SOAPIER

PIE

FDAR

 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

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

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

POMR

HIPAA