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narrative reports

story telling

Problem-oriented medical record

database, problem list, care plan, and progress notes

SOAP

subjective, obejective, assessment, plan

SOAPIE

subjective, objective, assessment, plan, intervention, evaluation

SBAR

situation, background, assessment, recommendation

PIE

problem, intervention, and evaulation

Focus Charting

involves the use of data, action, and response (DAR)

source record

separate section for each discipline

charting by exception

focuses on deviations from the established norm or abnormal findings; highlights trends or changes

case management

incorporates a multidisciplinary approach to documenting care

critical pathways

multidisciplinary care plans that include client problems, key interventions, and expected outcome.

admission nursing history forms

provide baseline data to compare with changes in the clients condition.

flow sheets

data entry of assessment such as vital signs, hygiene measures, ambulation, restraint checks

kardex

has activity, treatment, nursing care plan sections that organize information for quick references

acuity records

determine the hours of care and staff required for a given group of clients.

standardized care plan

preprinted, established guidelines used to care for the client

discharge summary forms

emphasize previous learing by the client and the care that should be continued.

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