health histories and documentation

nursing process

Assessment - gather data and recognise cues

Diagnosis - what is the actual/potential problem, analyse cues

Plan - generate solutions

Implementation - take action

Evaluation - evaluate outcomes, did it work

primary data

patient interviews, observations

secondary data

medical records, patient charts, family

tertiary data

nurse knowledge, textbooks

complete health assessment

health history, comprehensive head to toe exam

focused assessment

focus to a particular system and based on care goals

community assessment

data from primary and secondary sources

time-lapsed assessment

current status of client compared to previous baseline during and prior to treatment

functional assessment

ADLs, current and past mobility

quick priority assessment

scan for safety hazads

ensure safety equipment is functional

ABC - airways, breathing, circulation

primary/general survey

begins when you meet the client, continues throughout care

PQRSTU

P - precipitating - what makes it better/worse, what have you taken, did it help?

Q - quality - type of pain?

R - radiation - where is it felt, does it move to other areas?

S - severity - rate 0-10

T - timing - when did it start, sudden/gradual?

U - understanding - what do you think it means

BCCNM - purpose of documentation

communication to others about assessments, patient status, response to nursing interventions

safe and appropriate nursing care for others to review and plan their own contributions to care

professional and legal standards - the record of care is provided, evidence

narrative documentation

story like format

SOAP

subjective

objective

assessment

plan

DAR

data

action

response

DARP

data

action

response

plan

PIE

problem

intervention

evaluation

systems

organise by system

charting by exception

only document deviations from norma