Documentation Management System Notes

These flashcards cover key concepts and terminology from the documentation management system notes, crucial for understanding patient care documentation, nursing process, and clinical practices.

Documentation

The creation of a record that details a medical treatment, clinical test, or medical trial.

Clinical Documents

Must be timely, accurate, and outline the specific services provided to a patient.

FOCUS CHARTING (FDAR)

A method describing the patient's perspective and documenting the current status, progress, and response to interventions.

Data (in FOCUS charting)

Includes both subjective and objective information regarding the patient's condition.

Data (DAR)

Supporting evidence for why a note is written, indicating what the patient says and what the nurse observes.

Action (in FOCUS charting)

Describes the nursing interventions performed based on the data collected.

Response (in FOCUS charting)

Indicates how the patient responded to the actions taken.

Documentation Do's

Read other providers' notes, time and date all entries, document observations as they occur.

Documentation Don'ts

Do not chart in advance, make entries for someone else, or use meaningless phrases in notes.

Nursing Process

A systematic guide to client-centered care, including assessment, diagnosis, planning, implementation, and evaluation.

SMART goals

Specific, Measurable, Achievable, Relevant, Time-bound objectives used in planning nursing care.

Drug Computation Formula

D/S x V = Dose, where D is the Desired Dose, S is the Stock Dose, V is the Volume.

IV Flow Rate Calculation Formula

Total Volume (mL) / Infusion Time (min) x Drop Factor (gtts/mL).

Oxygen Therapy

The administration of oxygen as a therapeutic modality to relieve hypoxia.

Signs of Respiratory Distress

Indicators include cyanosis, difficulty breathing, and changes in consciousness.

Nasogastric Tube (NGT)

A tube inserted through the nostril into the stomach for feeding or medication delivery.

Oropharyngeal Suctioning

Used to provide oral hygiene and prevent infection in individuals with impaired swallowing.

Urinary Catheterization

The process of inserting a catheter to support urinary elimination in patients who cannot void naturally.

Catheter-Associated Urinary Tract Infections (CAUTI)

Common complications associated with indwelling urinary catheters.

Phototherapy

A treatment method using light to heal conditions like hyperbilirubinemia in neonates.

Integrated Management of Childhood Illnesses (IMCI)

A clinical guideline targeting children under 5 years to reduce mortality and morbidity from common diseases.

Basic Life Support (BLS) C-A-B Approach

A method to assess and treat patients in respiratory and cardiac distress: Circulation, Airway, Breathing.