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Documentation. Telana Fairchild Nurse Practitioner Students UMass - Worcester, Graduate School of Nursing N/NG 603B. Types of Documentation. Narrative Focused Flow-sheet By exception Problem oriented. Problem Oriented. Effective among health care team Includes patients input

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Documentation

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  1. Documentation Telana Fairchild Nurse Practitioner Students UMass - Worcester, Graduate School of Nursing N/NG 603B

  2. Types of Documentation Documentation Narrative Focused Flow-sheet By exception Problem oriented

  3. Problem Oriented Documentation Effective among health care team Includes patients input Easy to read/follow PIE: Problem, Intervention, Evaluation SOAP/ER/IER: Subjective, Objective, Assessment, Plans, Interventions, Evaluation, Revisions

  4. SOAPIER Documentation Subjective: “pt statement” c/o Objective: Nurses assessment, VS, General appearance Assessment: Identify problems Plan: Solutions to problems Intervention: Agreed Solutions to try Evaluation: Did it work? Revision: New Intervention

  5. References: Documentation College and Association of Registered Nurses of Alberta. (2006). Documentation guidelines for Registered Nurses. College and Association of Registered Nurses of Alberta, Edmonton, AB. Retrieved from: http://www.nurses.ab.ca/CarnaAdmin/Uploads/Documentation%20for%20Registered %20Nurses.pdf Scott, R.W. (2006). Legal Aspects of Documenting Patient Care for Rehabilitation Professionals (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers. South Carolina Department of Disabilities and Special Needs. (2006). Nursing documentation guidelines. Retrieved from: http://ddsn.sc.gov/providers/manualsandguidelines/Documents/HealthCareGuidelines/ NursingDocumentation.pdf

  6. What questions do you have? 6 Documentation

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