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17 Matching questions

  1. charting by exception
  2. SOAP
  3. source record
  4. acuity records
  5. SBAR
  6. admission nursing history forms
  7. critical pathways
  8. flow sheets
  9. Problem-oriented medical record
  10. case management
  11. narrative reports
  12. standardized care plan
  13. SOAPIE
  14. kardex
  15. discharge summary forms
  16. Focus Charting
  17. PIE
  1. a database, problem list, care plan, and progress notes
  2. b has activity, treatment, nursing care plan sections that organize information for quick references
  3. c focuses on deviations from the established norm or abnormal findings; highlights trends or changes
  4. d involves the use of data, action, and response (DAR)
  5. e subjective, objective, assessment, plan, intervention, evaluation
  6. f story telling
  7. g data entry of assessment such as vital signs, hygiene measures, ambulation, restraint checks
  8. h provide baseline data to compare with changes in the clients condition.
  9. i determine the hours of care and staff required for a given group of clients.
  10. j preprinted, established guidelines used to care for the client
  11. k subjective, obejective, assessment, plan
  12. l incorporates a multidisciplinary approach to documenting care
  13. m emphasize previous learing by the client and the care that should be continued.
  14. n situation, background, assessment, recommendation
  15. o multidisciplinary care plans that include client problems, key interventions, and expected outcome.
  16. p separate section for each discipline
  17. q problem, intervention, and evaulation