| A | B |
|---|
| DOCUMENTATION | PROVIDES 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 CARE | FOR THE PATIENT ADDS WRITTEN DOCUMENTATION TO THE MEDICAL RECORD OR CHART |
| DOCUMENTATION, ALSO CALLED CHARTING | IS USED TO TRACK THE APPLICATION OF THE NURSING PROCESS |
| THE WRITTEN NURSING PLAN PROVIDES | THE FRAMEWORK FOR THE NURSES DOCUMENTATION |
| THE MEDICAL RECORD OR CHART | CONTAINS DATA ON A PATIENT'S STAY IN THE HEALTH FACILITY OR WHILE UNDER THE CARE OF A HEALTH PROVIDER |
| THE MEDICAL RECORD | IS A LEGAL RECORD, IT'S CONTENTS MUST BE KEPT CONFIDENTIAL |
| CONFIDENTIAL | PRIVATE |
| ONLY THOSE HEALTH PROFESSIONALS CARING DIRECTLY FOR THE PATIENT | SHOULD HAVE ACCESS TO THE CHART |
| THE CHART | IS THE PROPERTY OF THE HEALTH FACILITY OR AGENCY, NOT THE PATIENT OR DOCTOR |
| GENERAL FORMS FOR HOSPITAL DOCUMENTATION | FACE SHEET, PHYSICIAN'S ORDERS, GRAPHIC SHEET, NURSING CARE PLAN, NURSE'S NOTES, ACTIVITY FLOWSHEET |
| (GENERAL FORMS) FACE SHEET | PATIENT 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 SHEET | RECORD OF SERIAL MEASUREMENTS AND OBSERVATIONS, EX: TEMP, PULSE, RESPIRATION, NURSING INTERVENTION |
| (GENERAL FORMS) NURSING CARE PLAN | PLAN OF CARE FOR THE PATIENT INCLUDING NURSING DGX'S, GOALS/EXPECTED OUTCOMES AND NURSING INTERVENTIONS |
| (GENERAL FORMS) NURSE'S NOTES | WRITTEN 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 SHEET | FORM 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 FORMS | DR'S RECORD OF THE PATIENT'S MEDICAL HX, FINDINGS OF THE CURRENT PHYSICAL EXAM |
| (GENERAL FORMS) NURSE'S ADMISSON HISTORY AND ASSESSMENT | NURSE'S CURRENT HX, HABITS, MEDS USUALLY TAKEN, PHYSICAL ASSESSMENT FINDINGS AT ADMISSION |
| (GENERAL FORMS) PROGESS SHEET | PHYSICIAN'S NOTES REGARDING THE PATIENT'S PROGRESS |
| (GENERAL FORMS) LABORATORY REPORTS | RESULTS OF LAB TESTS |
| (GENERAL FORMS) RADIOLOGY REPORTS | RESULTS OF X-RAY EXAMINATIONS |
| (GENERAL FORMS) ADMISSION FORMS | INFORMATION ON PATIENT IDENTIFICATION, CONDITIONS FOR ADMISSION, CONSENT FOR GENERAL MEDICAL AND NURSING CARE |
| (GENERAL FORMS) INTAKE & OUTPUT RECORD | SERIAL RECORD OF 24-HOUR INTAKE AND OUTPUT |
| (SPECIAL FORMS) ANCILLARY STAFF SHEETS | RECORDS OF TREATMENTS FOR PHYSICAL THERAPISTS, OCCUPATIONAL THERAPISTS, RESPIRATORY THERAPISTS... |
| (SPECIAL FORMS) DISCHARGE PLANNING SHEET | RECORDS BY SOCIAL SERVICES HOME HEALTH AGENCIES, AND CLINICAL NURSE SPECIALISTS REGARDING THE DISCHARGE PLANS AND NEEDS OF THE PATIENT |
| (SPECIAL FORMS) CONSULTATION SHEET | RECORD 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 FLOWSHEET | RECORD OF BLOOD SUGAR DETERMINATIONS AND AMOUNTS OF INSULIN ADMINISTERED |
| (MISC FORMS) PREOPERATIVE CHECK LIST | LIST USED TO VERIFY THAT THE PATIENT IS READY TO GO TO SURGERY |
| FREQUENT OBSERVATIONS SHEET | USED WHEN VERY FREQUENT MEASUREMENTS OF VITAL SIGNS OR NEUROLOGIC ASSESSMENT ARE NEEDED (AFTER SURGERY, OR AFTER HEAD TRAUMA) |
| (MISC FORMS) INTRAVENOUS FLOWSHEET | RECORD OF IV FLUIDS, AND ADDITIVES INFUSED, TYPE OF IV CATHETER IN USE, DATE TUBING WAS CHANGED, DATE DRESSING WAS APPLIED |
| (MISC FORM) DISCHARGE FORM | INFO 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 DISCHARGED | THE 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 STYLE | FOCUSES 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 CHARTING | WHICH CENTERS ON THE PATIENT FROM A POSITIVE PERSPECTIVE |
| (METHODS OF CHARTING) CHARTING BY EXCEPTION | FOCUSES ON DEVIATIONS FROM PREDEFINED NORMS, USING PRESET PROTOCOLS AND STANDARDS OF CARE |
| (METHODS OF CHARTING) COMPUTER-ASSISTED CHARTING | WHERE DATA ARE INPUT TO THE COMPUTER |
| (METHODS OF CHARTING) CASE MANAGEMENT SYSTEM CHARTING | WHICH TRACKS VARIANCES FROM THE CRITICAL PATHWAY |
| SOURCE ORIENTED OR NARRATIVE CHARTING ADVANTAGES | GIVES 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 DISADVANTAGES | IT 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 PARTS | THE DATABASE, PROBLEM LIST, THE PLAN, THE PROGRESS NOTES, AND THE DISCHARGE SUMMARY |
| AS THE POMR EVOLVED THE "SOAP FORMAT" FOR PROGRESS NOTES WAS MODIFIED | TO SOAPIE AND SOAPIER |
| S STAND FOR | SUBJECTIVE INFORMATION (SYMPTOMS) |
| O STANDS FOR | OBJECTIVE INFORMATION (SIGNS/FACTS) |
| A STANDS FOR | ASSESSMENT DATA |
| P STANDS FOR | IS THE PLAN |
| I STANDS FOR | IMPLEMENTION |
| E STANDS FOR | EVALUATION |
| R STANDS FOR | REVISION |
| ADVANTAGES OF THE POMR CHARTING METHOD | PROVIDES 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 METHOD | IT 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 METHOD | FOLLOWS NURSING PROCESS AND USES NURSING DGX WHILE PLACING THE PLAN OF CARE WITHIN THE NURSES PROGRESS NOTES |
| P STANDS FOR | PROBLEM IDENTIFICATION |
| I STANDS FOR | INTERVENTIONS |
| E STANDS FOR | EVALUATION |
| PIE DIFFERS FROM SOAP CHARTING | IT 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 CHART | THE 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 CHART | INTERVENTIONS PERFOMED ARE DOCUMENTED HERE |
| UNDER THE E OF THE PIE CHART | THE OUTCOMES OF THE INTERVENTIONS ARE EVALUATED AND DOCUMENTED HERE |
| WHEN ASSESSMENT DATA ARE ABNORMAL ON PIE CHARTS | A IS ADDED (APIE) |
| FOCUS CHARTING SIMILIAR TO POMR CHART | BUT 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 CHARTING | CONTAINS SUBJECTIVE AND OBJECTIVE INFO THAT DESCRIBES OR SUPPORTS THE FOCUS OF THE NOTE |
| THE ACTION COMPONENT INCLUDES | INTERVENTIONS PERFORMED OR TO BE IMPLEMENTED |
| THE RESPONSE COMPONENT | DESCRIBES THE OUTCOMES OF THE INTERVENTIONS AND WHETHER THE GOAL HAS BEEN MET |
| ADVANTAGES OF FOCUS CHARTING | COMPATIBLE 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 CHARTING | IF 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 METHOD | DEVELOPED 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 EXCEPTION | IS BASED ON THE ASSUMPTION THAT ALL STANDARDS OF PRACTICE ARE CARRIED OUT AND MET WITH A MORMAL OR EXPECTED RESPONSE UNLESS OTHERWISE DOCUMENTED |
| PROTOCOLS | STANDARD PROCEDURES |
| CHARTING BY EXCEPTION | A LONGHAND NOT IS WRITTEN ONLY WHEN THE STANDARDIZED STATEMENT ON THE FORM IS NOT MET, OTHERWISE A SIGNATURE IS NECESSARY |
| CHARTING BY EXCEPTION IS | THE 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 METHOD | MAY PRESENT SOME PROBLEMS WITH LEGALITIES WHEN A CHART IS CALLED INTO COURT BECAUSE ONLY ABNORMALITIES ARE DOCUMENTED IN WRITTEN WORDS |
| ADVANTAGES OF CHARTING BY EXCEPTION | HIGHLIGHTS ABNORMAL DATA/PATIENT TRENDS, DECREASES NARRATIVE CHARTING TIME, ELIMINATES DUPLICATE CHARTING |
| DISADVANTAGES OF CHARTING BY EXCEPTION | REQUIRES 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 CHARTING | DATE/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 CHARTING | SECURITY/CONFIDENTIALITY, INITAL COSTS PRICY, TRAINING STAFF COSTLY, COMPUTER DOWN TIME CAN CREATE PROBLEMS OF IMPUT, ACCESS, TRANSFER OF INFO |
| CASE MANAGEMENT SYSTEM CHARTING | METHOD 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 METHOD | PATIENTS 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 METHOD | SHOULD BE ACCURATE/BRIEF/COMPLETE, IT PRESENTS A PHOTOGRAPHIC VIEW OF THE PATIENT TO ANYONE WHO READS FOR NURSING NOTES |
| BREVITY IN CHARTING | A,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 THAN | BREVITY, STATE PROBLEM, WHAT YOU DID TO THE PROBLEM |
| THE KARDEX | WORK 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 INCLUDES | ROOM#, 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 SYMPTOM | LOCATION IN THE BODY-DESCRIBE THE EXACT LOCATION |
| S/S GUIDELINES...QUALITY | DESCRIBE IN PATIENTS WORDS, HEART ATTACK (CHEST IS SQUEEZED IN A VISE" |
| S/S GUIDELINES...QUANTITY | CHART INTENSITY OF SYMPTOMS...MILD/MODERATE/SEVERE...SCALE OF 1-10 |
| S/S/ GUIDELINES..CHRONOLOGY | NOTE THE SEQUENCE OF DEVELOPMENT 1/TIME/ONSET OF S/S..2/ DURATION..MIN/HR/DAYS,..PATTERN OF VARIATION/FREQUENCY |
| S/S GUIDELINES...SETTING | WHERE IS PATIENT...WHAT IS PATIENT DOING...WHO IS THE PATIENT..WHEN S/S OCCUR |
| S/S GUIDELINES...AGGRAVATING OR ALLEVIATING FACTORS | WHAT MAKES THE S/S WORSE OR BETTER..HOT SHOWER WORSE..EATING..MAKE IT WORSE |
| S/S GUIDELINES..ASSOCIATED MANIFESTATIONS | S/S RARELY OCCUR SINGLY...N/V..WEIGHT CHANGE |
| TYPES OF INFO TO BE DOCUMENTED | ADMISSION 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 CHARTING | BEFORE 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 MEDICINE | A 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 CORRECTLY | USE DICTIONARY IF NEEDED |
| IF YOU MAKE ERROR ON CHART, DRAW A LINE THROUGH THE INCORRECT WORD OR PHRASE AND WRITE THE WORD ERROR ABOVE IT | ADD 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 IS | THE PROPERTY OF THE HOSPITAL |
| THE PRIMARY PURPOSE OF CHARTING THE CARE OF A HOSPITALIZED PERSON IS TO PROVIDE | A WRITTEN HISTORY OR RECORD |
| THE TRADITIONAL SOURCE ORIENTED, NARRATIVE TYPE OF CHARTING IS CHARACTERIZED BY ALL OF THE FOLLOWING | EXCEPT THE DATABASE FORM |
| ONE CHARACTERISTIC DIFFERENTIATING SOURCE ORIENTED FROM POMR IS | THE SEPARATION OF NOTES ON MEDICAL CARE AND NURSING CARE |
| THE PROBLEM ORIENTED CHARTING, THE DATABASE DOES NOT CONTAIN | THE SOAP PROGRESS NOTES |
| THE PURPOSE OF THE SOAP FORMAT IN POMR CHARTING IS TO | RECORD THE PATIENTS PROGRESS |
| IN POMR CHARTING, ROUTINE INFO AND RECURRING OBSERVATION, SUCH AS INFO ON BATHS, BLOOD SUGAR TEST RESULTS ARE RECORDED ON FORMS CALLED | FLOWSHEETS |
| IN CHARTING BY EXCEPTION | PREDEFINED ASSESSMENT PARAMETERS, PROTOCOLS, AND STANDARDS ARE REQUIRED |
| A DISADVANTAGE OF COMPUTER ASSISSED CHARTING IS | ABSOLUTE SECURITY/CONFIDENTIALITY OF PATIENT RECORDS MAY BE DIFFICULT TO MAINTAIN |
| WHEN CHARTING THE PATIENTS CONDITION AND NURSING CARE, THE NURSE RECORDS | PATIENT STATMENTS AND BEHAVIORS THAT ARE OBSERVED OR MEASUREMENTS |
