frequency depending on the unit/hospital policy (hourly
patient rounds)
What are important methods in documentation?
confirming correct patient name before you make an entry
using black ink (if on paper)
using objective measurable terms
using only standard abbreviations and those accepted to the agency
timing and dating every entry
signing every entry
making sure there is a pt name or sticker on each page of chart
What are some unacceptable techniques in documentation?
charting for anyone other than yourself
signing anyone else's entry
using dittos, erasures, white out
scribbling over mistakes
What are some unaccepted abbrevations and symbols?
, U, IU, QD, QOD, trailing zero, lack of leading zero, MS, MSO4/MgSO4, <, >, @, cc
What is the major purpose of the hand-off report?
To maintain continuity of care
What is SOAPIER documentation?
• S - Subjective data
• O - Objective data
• A - Assessment
• P - Plan
• I - Intervention
• E - Evaluation
• R- Response
What is PIE charting?
• Problem
• Intervention
• Evaluation
problems numbered and charted/evaluated daily
problems drop from chart when they are resolved.
What is DAR charting?
Data
Action
Response
problem-oriented charting format
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