Telana Fairchild Nurse Practitioner Students UMass Worcester Graduate School of Nursing NNG 603B 1 Narrative Focused Flowsheet By exception Problem oriented Types of Documentation ID: 406269
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Documentation
Telana FairchildNurse Practitioner StudentsUMass - Worcester, Graduate School of NursingN/NG 603B
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NarrativeFocused
Flow-sheetBy exceptionProblem orientedTypes of Documentation
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Effective among health care teamIncludes patients input
Easy to read/followPIE: Problem, Intervention, EvaluationSOAP/ER/IER: Subjective, Objective, Assessment, Plans, Interventions, Evaluation, Revisions3Problem Oriented
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Subjective: “
pt statement” c/oObjective: Nurses assessment, VS, General appearanceAssessment: Identify problems Plan: Solutions to problems Intervention: Agreed Solutions to tryEvaluation: Did it work?Revision: New Intervention
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SOAPIER
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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/CarnaAdmin/Uploads/Documentation%20for%20Registered %20Nurses.pdf
Scott, R.W. (2006). Legal Aspects of
Documenting
Patient Care for
Rehabilitation Professionals
(3rd
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/HealthCareGuidelines
/ NursingDocumentation.pdf
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References:
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What questions do you have?
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