documentation and reporting

documentation

serves as a permanent record of client information and care

reporting

takes place when two or more people share info about client care

fluid balance record

i & o monitoring

graphic record

tpbrp

nurses progress notes

soapie or fdar

soapie

subjective, objective, assessment, plan, intervention, evaluation

fdar

focus, data, action, response

informed consent

means the client understands the reason and risks of proposed intervention

legibility

avoid erasures and obliterate writing
state the reason of error
sign and date the correction
print if necessary

organization

start every entry w date and time
chronological order
chard medications immediately after administration
sign your name after each entry

accuracy

use correct spelling and grammar
write complete sentences

confidentiality

the nurse is responsible for protecting the privacy and confidentiality of client interaction, assessment, and care

factual record

contains descriptive, objective info about what a nurse sees, hears, feels, and smells

objective description

result of direct observation and measurement

pomr

problem oriented medical record

source-oriented charting

most traditional
narrative recording by each member
admission, physician’s notes

focus charting

method of identifying and organizing the narrative documentation of all client concerns
uses a columnar format

electronic health record (ehr)

computerized documentation
increases quality of documentation and save time

summary/ hand off reports

commonly occur at change of shift

walking rounds report

occur in the client’s room

incident report

used to document any unusual occurrence or accident

telephone order

provide clear accurate concise info