Documentation Telana Fairchild Nurse Practitioner Students UMass Worcester
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Documentation Telana Fairchild Nurse Practitioner Students UMass - Worcester, Graduate School of Nursing N/NG 603 B 1
Types of Documentation • • • 2 Narrative Focused Flow-sheet By exception Problem oriented | Documentation | April 15, 2013
Problem Oriented • • • 3 Effective among health care team Includes patients input Easy to read/follow PIE: Problem, Intervention, Evaluation SOAP/ER/IER: Subjective, Objective, Assessment, Plans, Interventions, Evaluation, Revisions | Documentation | April 15, 2013
SOAPIER • Subjective: “pt statement” c/o • Objective: Nurses assessment, VS, General appearance • Assessment: Identify problems • Plan: Solutions to problems • Intervention: Agreed Solutions to try • Evaluation: Did it work? • Revision: New Intervention 4 | Documentation | April 15, 2013
References: College and Association of Registered Nurses of Alberta. (2006). Documentation guidelines for Registered Nurses. College and Association of Registered Nurses of Alberta, Edmonton, AB. Retrieved from: http: //www. nurses. ab. ca/Carna. Admin/Uploads/Documentation%20 for%20 Registered %20 Nurses. pdf Scott, R. W. (2006). Legal Aspects of Documenting Patient Care for Rehabilitation Professionals (3 rd ed. ). Sudbury, MA: Jones and Bartlett Publishers. South Carolina Department of Disabilities and Special Needs. (2006). Nursing documentation guidelines. Retrieved from: http: //ddsn. sc. gov/providers/manualsandguidelines/Documents/Health. Care. Guidelines/ Nursing. Documentation. pdf 5 | Documentation | April 15, 2013
What questions do you have? 6 Documentation April 15, 2013 6