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DOCUMENTATION OF NURSING CARE, CHAPTER 8

FUNDAMENTALS OF NURSING BY PAMELA SUE
(IT IS BEST TO PRINT OUT THE LIST OF TERMS AND USE THIS AS A STUDY GUIDE)

AB
DOCUMENTATIONPROVIDES A WRITTEN RECORD OF THE HISTORY, TREATMENT, CARE AND RESPONSE OF THE PATIENT WHILE UNDER THE CARE OF A HEALTH CARE PROVIDER
EACH PERSON WHO PROVIDES CAREFOR THE PATIENT ADDS WRITTEN DOCUMENTATION TO THE MEDICAL RECORD OR CHART
DOCUMENTATION, ALSO CALLED CHARTINGIS USED TO TRACK THE APPLICATION OF THE NURSING PROCESS
THE WRITTEN NURSING PLAN PROVIDESTHE FRAMEWORK FOR THE NURSES DOCUMENTATION
THE MEDICAL RECORD OR CHARTCONTAINS DATA ON A PATIENT'S STAY IN THE HEALTH FACILITY OR WHILE UNDER THE CARE OF A HEALTH PROVIDER
THE MEDICAL RECORDIS A LEGAL RECORD, IT'S CONTENTS MUST BE KEPT CONFIDENTIAL
CONFIDENTIALPRIVATE
ONLY THOSE HEALTH PROFESSIONALS CARING DIRECTLY FOR THE PATIENTSHOULD HAVE ACCESS TO THE CHART
THE CHARTIS THE PROPERTY OF THE HEALTH FACILITY OR AGENCY, NOT THE PATIENT OR DOCTOR
GENERAL FORMS FOR HOSPITAL DOCUMENTATIONFACE SHEET, PHYSICIAN'S ORDERS, GRAPHIC SHEET, NURSING CARE PLAN, NURSE'S NOTES, ACTIVITY FLOWSHEET
(GENERAL FORMS) FACE SHEETPATIENT DATA INCLUDING: NAME, ADDRESS, PHONE, NEXT OF KIN, HOSPITAL ID#, RELIGION, EMPLOYER, INSURANCE, OCCUPATION, ADMITTING DR, ADMITTING DGX
(GENERAL FORMS) PHYSICIAN'S ORDERS INCLUDES:THE PHYSICIAN'S DIRECTIVES FOR PATIENT CARE
(GENERAL FORMS) GRAPHIC SHEETRECORD OF SERIAL MEASUREMENTS AND OBSERVATIONS, EX: TEMP, PULSE, RESPIRATION, NURSING INTERVENTION
(GENERAL FORMS) NURSING CARE PLANPLAN OF CARE FOR THE PATIENT INCLUDING NURSING DGX'S, GOALS/EXPECTED OUTCOMES AND NURSING INTERVENTIONS
(GENERAL FORMS) NURSE'S NOTESWRITTEN REPORT OF THE NURSING PROCESS (ASSESSMENT, NURSING DGX, PLANNING, IMPLEMENTATION, EVALUATION) RECORD OF INTERVENTIONS IMPLEMENTED AND THE PATIENTS REPSPONSE TO THEM
(GENERAL FORMS) ACTIVITY FLOW SHEETFORM ON WHICH CHECKMARKS OR SHORT ENTRIES ARE MADE TO INDICATE DIETARY INTAKE, TYPE OF BATH, WOUND DRESSING CHANGES, OXYGEN IN USE, DR VISITS, EQUIPMENT IN USE, ACTIVITY LEVEL...
(GENERAL FORMS) MEDICATION ADMINISTRATION RECORD (MAR)DOCUMENTATION OF ALL MEDS ORDERED, DOSES GIVEN, DOSES NOT TAKEN BY THE PATIENT
(GENERAL FORMS) HISTORY & PHYSICAL EXAMINATION FORMSDR'S RECORD OF THE PATIENT'S MEDICAL HX, FINDINGS OF THE CURRENT PHYSICAL EXAM
(GENERAL FORMS) NURSE'S ADMISSON HISTORY AND ASSESSMENTNURSE'S CURRENT HX, HABITS, MEDS USUALLY TAKEN, PHYSICAL ASSESSMENT FINDINGS AT ADMISSION
(GENERAL FORMS) PROGESS SHEETPHYSICIAN'S NOTES REGARDING THE PATIENT'S PROGRESS
(GENERAL FORMS) LABORATORY REPORTSRESULTS OF LAB TESTS
(GENERAL FORMS) RADIOLOGY REPORTSRESULTS OF X-RAY EXAMINATIONS
(GENERAL FORMS) ADMISSION FORMSINFORMATION ON PATIENT IDENTIFICATION, CONDITIONS FOR ADMISSION, CONSENT FOR GENERAL MEDICAL AND NURSING CARE
(GENERAL FORMS) INTAKE & OUTPUT RECORDSERIAL RECORD OF 24-HOUR INTAKE AND OUTPUT
(SPECIAL FORMS) ANCILLARY STAFF SHEETSRECORDS OF TREATMENTS FOR PHYSICAL THERAPISTS, OCCUPATIONAL THERAPISTS, RESPIRATORY THERAPISTS...
(SPECIAL FORMS) DISCHARGE PLANNING SHEETRECORDS BY SOCIAL SERVICES HOME HEALTH AGENCIES, AND CLINICAL NURSE SPECIALISTS REGARDING THE DISCHARGE PLANS AND NEEDS OF THE PATIENT
(SPECIAL FORMS) CONSULTATION SHEETRECORD OF ANOTHER PHYSICIAN CALLED IN TO CONSULT BY THE ATTENDING DR
(SPECIAL FORMS) SURGICAL OR TREATMENT CONSENT FORM)PATIENT AUTHORIZATION FOR SURGERY OR TREATMENT
(MISC FORMS) DIABETIC FLOWSHEETRECORD OF BLOOD SUGAR DETERMINATIONS AND AMOUNTS OF INSULIN ADMINISTERED
(MISC FORMS) PREOPERATIVE CHECK LISTLIST USED TO VERIFY THAT THE PATIENT IS READY TO GO TO SURGERY
FREQUENT OBSERVATIONS SHEETUSED WHEN VERY FREQUENT MEASUREMENTS OF VITAL SIGNS OR NEUROLOGIC ASSESSMENT ARE NEEDED (AFTER SURGERY, OR AFTER HEAD TRAUMA)
(MISC FORMS) INTRAVENOUS FLOWSHEETRECORD OF IV FLUIDS, AND ADDITIVES INFUSED, TYPE OF IV CATHETER IN USE, DATE TUBING WAS CHANGED, DATE DRESSING WAS APPLIED
(MISC FORM) DISCHARGE FORMINFO ABOUT INSTURCTIONS GIVEN REGARDING WOUND CARE, MEDS, REST, ACTIVITY RESTRICTIONS, NEEDED EXERCISES, DIET AND S/S TO REPORT TO THE DR, ALSO INCLUDES WHEN TO NEXT SEE THE DR
AFTER THE PATIENT HAS BEEN DISCHARGEDTHE CHART IS SENT TO THE MEDICAL RECORDS OR HEALTH INFO DEPT FOR SAFEKEEPING, IT CAN BE RETRIEVED IF THE PATIENT IS ADMITTED TO SERVICE AGAIN WITHIN A 10 YEAR SPAN
(METHODS OF CHARTING) SOURCE-ORIENTED OR NARRATIVE STYLEFOCUSES ON THE PATIENT'S DISEASE
(METHODS OF CHARTING) PROBLEM-ORIENTED MEDICAL RECORD (POMR)FOCUSES ON THE PROBLEMS EXPERIENCED BY THE PATIENT AS A RESULT OF BEING ILL OR ON THE DEFINED NURSING DGX REFLECTING THOSE PROBLEMS
(METHODS OF CHARTING) FOCUS CHARTINGWHICH CENTERS ON THE PATIENT FROM A POSITIVE PERSPECTIVE
(METHODS OF CHARTING) CHARTING BY EXCEPTIONFOCUSES ON DEVIATIONS FROM PREDEFINED NORMS, USING PRESET PROTOCOLS AND STANDARDS OF CARE
(METHODS OF CHARTING) COMPUTER-ASSISTED CHARTINGWHERE DATA ARE INPUT TO THE COMPUTER
(METHODS OF CHARTING) CASE MANAGEMENT SYSTEM CHARTINGWHICH TRACKS VARIANCES FROM THE CRITICAL PATHWAY
SOURCE ORIENTED OR NARRATIVE CHARTING ADVANTAGESGIVES INFO ON PATIENTS CONDITION & CARE IN CHRONOLOGICAL ORDER, INDICATES THE BASELINE CONDITION FOR EACH SHIFT, INCLUDES ASPECTS OF ALL STEPS OF THE NURSING PROCESSES
SOURCE ORIENTED OR NARRATIVE CHARTING DISADVANTAGESIT ENCOURAGES DOCUMENTATION OF BOTH NORMAL AND ABNORMAL FINDINGS, MAKING IT DIFFICULT TO SEPARATE PERTINENT FROM IRRELEVANT INFO, IT REQUIRES EXTENSIVE CHARTING TIME BY THE STAFF, IT DISCOURAGES DR'S AND OTHER HEALTH MEMBERS FROM READING ALL PARTS OF THE CHART BECAUSE OF LONG DESCRIPTIVE ENTRIES
PROBLEM ORIENTED MEDICAL RECORD (POMR)DEVELOPED BY DR LAWRENCE WEED, USED SINCE 1960,
PROBLEM ORIENTED MEDICAL RECORD DOCUMENTATION (POMR)FOCUSES ON THE PATIENT STATUS RATHER THAN ON MEDICAL OR NURSING CARE, ITS PROBLEM SOLVING APPROACH TO PATIENT CARE AND PROVIDES A METHOD FOR COMMUNICATING WHAT, WHEN, AND HOW THINGS ARE TO BE DONE IN ORDER TO MEET THE NEEDS OF THE PATIENT
THE POMR CONTAINS 5 BASIC PARTSTHE DATABASE, PROBLEM LIST, THE PLAN, THE PROGRESS NOTES, AND THE DISCHARGE SUMMARY
AS THE POMR EVOLVED THE "SOAP FORMAT" FOR PROGRESS NOTES WAS MODIFIEDTO SOAPIE AND SOAPIER
S STAND FORSUBJECTIVE INFORMATION (SYMPTOMS)
O STANDS FOROBJECTIVE INFORMATION (SIGNS/FACTS)
A STANDS FORASSESSMENT DATA
P STANDS FORIS THE PLAN
I STANDS FORIMPLEMENTION
E STANDS FOREVALUATION
R STANDS FORREVISION
ADVANTAGES OF THE POMR CHARTING METHODPROVIDES DOCUMENTATION OF COMPREHENSIVE CARE BY FOCUSING ON PATIENTS / PROBLEMS, IT PROMOTES THE PROBLEM SOLVING APPROACH TO CARE, IT IMPROVES CONTINUITY OF CARE & COMMUNICATION BY KEEPING RELEVANT DATA TO A PROBLEM ALL IN ONE PLACE SO THAT IS READY TO ALL PROVIDING CARE, ALLOWS EASY AUDITING OF PATIENT RECORDS IN EVALUATION STAFF PERFORMANCE & QUALITY OF PATIENT CARE, REQUIRES CONTINUOUS EVALUATION & REVISION OF THE PLAN OF CARE, REINFORCES APPLICATION OF THE NURSING PROCESS
DISADVANTAGES OF THE POMR CHARTING METHODIT RESULTS IN LOSS OF CHRONOLOGIC CHARTING, IT IS MORE DIFFICULT TO TRACK TRENDS IN PATIENT STATUS, IT FRAGMENTS DATA BECAUSE OF THE INCREASED NUMBER OF FLOW SHEETS REQUIRED
PIE CHARTING METHODFOLLOWS NURSING PROCESS AND USES NURSING DGX WHILE PLACING THE PLAN OF CARE WITHIN THE NURSES PROGRESS NOTES
P STANDS FORPROBLEM IDENTIFICATION
I STANDS FORINTERVENTIONS
E STANDS FOREVALUATION
PIE DIFFERS FROM SOAP CHARTINGIT DOES NOT USE A TRADITIONAL NURSING CARE PLAN OR REQUIRE NARRATIVE CHARTING OF THE ASSESSMENT DATA AS LONG AS THEY ARE NORMAL
UNDER THE P OF THE PIE CHARTTHE PROBLEMS,TEACHING AND DISCHARGE NEEDS ARE LISTED, NURSING DGX ARE KEPT ON A PROBLEM LIST, AND EACH CHARTING ENTRY IS MARKED WITH THE PROBLEM NUMER AND TITLE, WITH THIS METHOD THE DAILY ASSESSMENT INFO IS PLACED ON FLOWSHEETS AND DUPLICATION OF THE INFO IS AVOIDED
UNDER THE I OF THE PIE CHARTINTERVENTIONS PERFOMED ARE DOCUMENTED HERE
UNDER THE E OF THE PIE CHARTTHE OUTCOMES OF THE INTERVENTIONS ARE EVALUATED AND DOCUMENTED HERE
WHEN ASSESSMENT DATA ARE ABNORMAL ON PIE CHARTSA IS ADDED (APIE)
FOCUS CHARTING SIMILIAR TO POMR CHARTBUT IT SUBSTITUES FOCUS FOR THE PROBLEM, ELIMINATING THE NEGATIVE CONNOTATION ATTACHED TO THE PROBLEM
FOCUS CHARTING IS AT A NURSES DGX (PAIN), A PROBLEM (PRESSURE SORE), CONCERN (DECREASED FOOD INTAKE), A SIGN (FEVER), SYMPTOM (ANXIETY) OR EVENT (RETURN FROM SURGERY)THE NOTE HAS 3 COMPONENTS (D-DATA), (A-ACTION) AND (R-RESPONSE)
THE DATA FOR FOCUS CHARTINGCONTAINS SUBJECTIVE AND OBJECTIVE INFO THAT DESCRIBES OR SUPPORTS THE FOCUS OF THE NOTE
THE ACTION COMPONENT INCLUDESINTERVENTIONS PERFORMED OR TO BE IMPLEMENTED
THE RESPONSE COMPONENTDESCRIBES THE OUTCOMES OF THE INTERVENTIONS AND WHETHER THE GOAL HAS BEEN MET
ADVANTAGES OF FOCUS CHARTINGCOMPATIBLE WITH THE USE OF THE NURSING PROCESS, SHORTENS CHARTING TIME BY USING MANY FLOWSHEETS/CHECKLISTS, FOCUS IS NOT LIMITED TO PROBLEMS OR NURSING DGX
DISADVANTAGES OF FOCUS CHARTINGIF THE DATABASE IS NOT SUFFICIENT, PATIENT PROBLEMS MAY BE MISSED, IT DOES NOT ADHERE TO CHARTING WITH THE FOCUS ON NURSING DIAGNOSES AND EXPECTED OUTCOMES
CHARTING BY EXCEPTION METHODDEVELOPED BY EARLY 80'S, BY NURSES AT ST LUKES MEDICAL CENTER IN MILWAUKEE, WI, THE GOAL WAS TO DECREASE THE LONG NARRATIVE ENTRIES OF TRADITIONAL CHARTING SYSTEMS AND REDUCE DUPLICATE DATA
CHARTING BY EXCEPTIONIS BASED ON THE ASSUMPTION THAT ALL STANDARDS OF PRACTICE ARE CARRIED OUT AND MET WITH A MORMAL OR EXPECTED RESPONSE UNLESS OTHERWISE DOCUMENTED
PROTOCOLSSTANDARD PROCEDURES
CHARTING BY EXCEPTIONA LONGHAND NOT IS WRITTEN ONLY WHEN THE STANDARDIZED STATEMENT ON THE FORM IS NOT MET, OTHERWISE A SIGNATURE IS NECESSARY
CHARTING BY EXCEPTION ISTHE DIRECT OPPOSITE OF THE SAYING" IF IT WASNT CHARTED, IT WASNT DONE", IT ASSUMES THAT UNLESS DOCUMENTATION TO THE CONTRARY, ALL STANDARDS AND PROTOCOLS WERE FOLLOWED AND ALL ASSESSMENT VALUES WERE WITHIN ACCEPTED LIMITS
CHARTING BY EXCEPTION METHODMAY PRESENT SOME PROBLEMS WITH LEGALITIES WHEN A CHART IS CALLED INTO COURT BECAUSE ONLY ABNORMALITIES ARE DOCUMENTED IN WRITTEN WORDS
ADVANTAGES OF CHARTING BY EXCEPTIONHIGHLIGHTS ABNORMAL DATA/PATIENT TRENDS, DECREASES NARRATIVE CHARTING TIME, ELIMINATES DUPLICATE CHARTING
DISADVANTAGES OF CHARTING BY EXCEPTIONREQUIRES DEVELOPMENT OF DETAILED PROTOCOLS/STANDARDS, REQUIRES RETRAINING STAFF TO USE UNFAMILIAR METHODS OF RECORD KEEPING/RECORDING, NURSES BECOME SO USED TO NOT CHARTING THAT IMPORTANT DATA IS SOMETIMES OMITTED
ADVANTAGES OF COMPUTER ASSISTED CHARTINGDATE/TIME AUTOMATICALLY RECORDED, NOTES ARE LEGIBLE, QUICK COMMUNICATION BETWEEN DEPTS, INFO MORE ACCURATE, COST EFFECTIVE, ELECTRONIC RECORDS ARE ACHIEVED QUICKLY, HOSPITAL GETS PAID FASTER
DISADVANTAGES OF COMPUTER ASSISTED CHARTINGSECURITY/CONFIDENTIALITY, INITAL COSTS PRICY, TRAINING STAFF COSTLY, COMPUTER DOWN TIME CAN CREATE PROBLEMS OF IMPUT, ACCESS, TRANSFER OF INFO
CASE MANAGEMENT SYSTEM CHARTINGMETHOD OF ORGANIZING PATIENT CARE THROUGH AN EPISODE OF ILLNESS SO THAT THE CLINICAL OUTCOMES ARE ACHIEVED WITHIN AN EXPECTED TIME AND A PREDICTABLE COST. A CRITICAL PATHWAY TAKES THE PLACE OF THE NURSING CARE PLAN
THE CHARTING PROCESS METHODPATIENTS NEEDS/PROBLEMS/ACTIVITIES SHOULD BE PRESENTED IN TERMS OF BEHAVIORS, THE NOTES FOCUS ON THE IMMEDIATE PAST AND THE PRESENT, NEVER THE FUTURE
THE CHARTING PROCESS METHODSHOULD BE ACCURATE/BRIEF/COMPLETE, IT PRESENTS A PHOTOGRAPHIC VIEW OF THE PATIENT TO ANYONE WHO READS FOR NURSING NOTES
BREVITY IN CHARTINGA,AN,THE CAN BE OMITTED, PATIENT IS LEFT OUT, EACH STATEMENT SHOULD BEGIN WITH A CAPITAL LETTER AND END WITH A PERIOD.
COMPLETENESS IS MORE IMPORTANT THANBREVITY, STATE PROBLEM, WHAT YOU DID TO THE PROBLEM
THE KARDEXWORK TOOL, NEEDS TO BE KEPT UP TO DATE, QUICK REFERENCE FOR CURRENT INFO ABOUT PAIIENT AND ORDERED TREATMENTS, UNIT SECRETARY HAS IT AND UPDATES IT WITH THE PRIMARY NURSE
THE KARDEX INCLUDESROOM#, NAME, AGE, SEX, ADMITTING DGX, DR'S NAME, SURGERY DATE, DIET, TESTS/PROCEDURES, ACTIVITY LEVEL, NURSING ORDERS FOR ASSISTIVE/COMFORT/, MEDS, IVS
GUIDELINES FOR CHARTING ABOUT A SIGN OR SYMPTOMLOCATION IN THE BODY-DESCRIBE THE EXACT LOCATION
S/S GUIDELINES...QUALITYDESCRIBE IN PATIENTS WORDS, HEART ATTACK (CHEST IS SQUEEZED IN A VISE"
S/S GUIDELINES...QUANTITYCHART INTENSITY OF SYMPTOMS...MILD/MODERATE/SEVERE...SCALE OF 1-10
S/S/ GUIDELINES..CHRONOLOGYNOTE THE SEQUENCE OF DEVELOPMENT 1/TIME/ONSET OF S/S..2/ DURATION..MIN/HR/DAYS,..PATTERN OF VARIATION/FREQUENCY
S/S GUIDELINES...SETTINGWHERE IS PATIENT...WHAT IS PATIENT DOING...WHO IS THE PATIENT..WHEN S/S OCCUR
S/S GUIDELINES...AGGRAVATING OR ALLEVIATING FACTORSWHAT MAKES THE S/S WORSE OR BETTER..HOT SHOWER WORSE..EATING..MAKE IT WORSE
S/S GUIDELINES..ASSOCIATED MANIFESTATIONSS/S RARELY OCCUR SINGLY...N/V..WEIGHT CHANGE
TYPES OF INFO TO BE DOCUMENTEDADMISSION NOTE, MOOD/CONCERNS, ASSESSMENT DATA FOR ALL BODY SYSTEMS, BODY CARE, DIET/FLUIDS, ACTIVITY LEVEL, WOUND CARE, I/O, OXYGEN IN USE, MENTAL STATE/MOOD, DIAGNOSTIC TESTS, MEDS, IV'S, SLEEP, POSTOP, TEACHING, DR'S VISITS/CALLS TO DR, SPECIMEN INFO, PROCEDURES, TUBES/EQUIP IN USE, TRAVEL FROM THE UNIT, VISITORS, DISCHARGE, DEATH
GENERAL GUIDELINES FOR CHARTINGBEFORE BEGINNING TO CHART, VERIFY NAME ON CHART AND THE PAGE, EACH PAGE SHOULD HAVE IMPRINT OF NAME AND HOSPITAL NUMBER ON IT, USE BLACK INK, DATE/TIME OF EACH ENTRY IN MILITARY TIME, CHART THE INITIAL ASSESSMENT, CHARTING IS DONE ONLY BY THE PERSON WHO MADE OBSERVATION/PROCEDURE AND WHO IS LEGALLY RESPONSIBLE, AFTER NOTE IS COMPLETE SIGN WITH ONE INITAL PLUS LAST NAME AND TITLE, P. KIRKWOOD, SPN, CHART OBJECTIVE DATA AFTER EACH TASK/ NOTHING IS CHARTED BEFORE IT IS ACTUALLY DONE, NO BLANK LINES ARE LEFT IN CHARTING, A LATE ENTRY MAY BE MADE IF SOMETHING HAS BEEN FORGOTTEN, WRITE TIME OF ENTRY/CIRCLE IT AND WRITE LATE ENTRY AND YOUR INITALS ABOVE THE TIME, CLARIFY ID CARE GIVEN BY ANOTHER HEALTH PERSON,
WHEN A PERSON REFUSES MEDICINEA CIRCLE IS PLACED ON THE MAR RECORD AROUND THE TIME THE MED WAS TO BE GIVEN, AN EXPLAIN REFUSAL IN PROGRESS NOTES. REFUSAL OF TREATMENTS ARE HERE ALSO, ALSO EXACT WORDS PATIENT USED WHILE REFUSING
SPELL CHART ENTRIES CORRECTLYUSE DICTIONARY IF NEEDED
IF YOU MAKE ERROR ON CHART, DRAW A LINE THROUGH THE INCORRECT WORD OR PHRASE AND WRITE THE WORD ERROR ABOVE ITADD THE DATE/MY INITIALS, SOME WRITE MISTAKEN ENTRY OR INCORRECT ENTRY RATHER THAN ERROR
THE RECORD OF THE PATIENTS MEDICAL AND NURSING CARE WHILE THE PATIENT IS IN THE HOSPITAL ISTHE PROPERTY OF THE HOSPITAL
THE PRIMARY PURPOSE OF CHARTING THE CARE OF A HOSPITALIZED PERSON IS TO PROVIDEA WRITTEN HISTORY OR RECORD
THE TRADITIONAL SOURCE ORIENTED, NARRATIVE TYPE OF CHARTING IS CHARACTERIZED BY ALL OF THE FOLLOWINGEXCEPT THE DATABASE FORM
ONE CHARACTERISTIC DIFFERENTIATING SOURCE ORIENTED FROM POMR ISTHE SEPARATION OF NOTES ON MEDICAL CARE AND NURSING CARE
THE PROBLEM ORIENTED CHARTING, THE DATABASE DOES NOT CONTAINTHE SOAP PROGRESS NOTES
THE PURPOSE OF THE SOAP FORMAT IN POMR CHARTING IS TORECORD THE PATIENTS PROGRESS
IN POMR CHARTING, ROUTINE INFO AND RECURRING OBSERVATION, SUCH AS INFO ON BATHS, BLOOD SUGAR TEST RESULTS ARE RECORDED ON FORMS CALLEDFLOWSHEETS
IN CHARTING BY EXCEPTIONPREDEFINED ASSESSMENT PARAMETERS, PROTOCOLS, AND STANDARDS ARE REQUIRED
A DISADVANTAGE OF COMPUTER ASSISSED CHARTING ISABSOLUTE SECURITY/CONFIDENTIALITY OF PATIENT RECORDS MAY BE DIFFICULT TO MAINTAIN
WHEN CHARTING THE PATIENTS CONDITION AND NURSING CARE, THE NURSE RECORDSPATIENT STATMENTS AND BEHAVIORS THAT ARE OBSERVED OR MEASUREMENTS


Pamela Sue

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