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Chapter 7 Documentation of Nursing Care
Purposes of Documentation ,[object Object],[object Object],[object Object],[object Object],[object Object]
Purposes of Documentation ,[object Object],[object Object],[object Object]
Documentation and the  Nursing Process ,[object Object],[object Object],[object Object],[object Object]
The Medical Record ,[object Object],[object Object],[object Object]
Methods of Documentation (Charting) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Source-Oriented or  Narrative Charting ,[object Object],[object Object],[object Object]
Source-Oriented or  Narrative Charting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Example of source-oriented (narrative charting)
Problem-Oriented Medical Record Charting (POMR) ,[object Object],[object Object]
Problem-Oriented Medical Record Charting (POMR) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Problem-Oriented Medical Record Charting (POMR) ,[object Object],[object Object],[object Object],[object Object]
PIE Charting ,[object Object],[object Object],[object Object],[object Object]
Example of PIE (problem, intervention, evaluation) charting
Focus Charting ,[object Object],[object Object],[object Object],[object Object],[object Object]
Focus Charting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Example of focus charting
Charting by Exception ,[object Object],[object Object]
Charting by Exception ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Computer-Assisted Charting ,[object Object],[object Object],[object Object],[object Object],[object Object]
Computer-Assisted Charting ,[object Object],[object Object],[object Object],[object Object]
Computer-Assisted Charting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Computer-Assisted Charting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Management  System Charting ,[object Object],[object Object]
Accuracy in Charting ,[object Object],[object Object]
Brevity in Charting ,[object Object],[object Object],[object Object],[object Object],[object Object]
Legibility and Completeness  in Charting ,[object Object],[object Object],[object Object]
The Kardex ,[object Object],[object Object],[object Object]
Information on the Kardex  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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