Exam (elaborations)
(NURS 2106) Unit 5 Reporting & Documentation
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(NURS 2106) Unit 5 Reporting & Documentation
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(NURS 2106) Unit 5 Reporting &Documentation
6 Important characteristics for quality documentation - ANS-- Factual
- Accurate
- Complete
- Current
- Organized
- Comply with standards
Common format of nursing notes - ANS-SOAP - Subjective data, Objective data,
Assessment, Plan
PIE - Problem, Intervention, Evaluation
DAR - Data, Action, Response
CBE - Charting By Exception
Documentation - ANS-Anything written or electronically generated that describes the
status of a patient or the care given to that client
(Health record, client record, Charts)
E(H/M)R - ANS-Electronic (Health/Medical) Record
Methods of Documentations - Charting by Exception - ANS-Clients meets all standards
unless otherwise documented
Methods of Documentations - Narrative - ANS-Story-like format to document information
Methods of Documentations - Problem Oriented - ANS-Primary focus on patients'
individual problems
Methods of Documentations - Source Charting - ANS-Each discipline (ex: nursing,
social work, physiotherapist) has a separate section to record data.
Purpose of documentation - ANS-- Communication/Care planning
- Funding and resource management
- Auditing and monitoring
- Research
- Education
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