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Documentation

Documentation

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Documentation

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  1. Documentation Recording and Reporting

  2. Communication in health care • Discussion • Reporting • Oral • Written • Taped • Charting

  3. Recording – The Chart • Patient’s health care information • Purposes • Communication • audit • research • education

  4. Recording– The Chart • Nursing documentation • Assessment • Care plan • Narrative notes • Flow sheets • Medication records (MAR) • Discharge summary • Incident report is not part of the chart

  5. Guidelines for Documentation • Content • Format • Timing

  6. Problem-oriented record • S-O-A-P-I-E-R • A-P-I-E

  7. Source-oriented record • Separate form for each group • Nurses notes are usually narrative • Flow sheets used extensively

  8. Care Paths • Also known as • Critical paths • MAPS • Charting by exception

  9. Computer documentation • Electronic transmission to regulatory agencies • Purchasers of health care demanding evidence of quality • Nursing leaders calling for outcomes database • Managed care organizations want to track the client across continuum of care

  10. Reporting • Forms • Change of Shift • Basic Identifying data • Current health status • Orders • Summary • Transfer/DC