DOCUMENTATION | 暗記メーカー

暗記メーカー

DOCUMENTATION

8問 • 9ヶ月前

問題一覧

1

is any written or electronically generated information about a client that describes the care or service provided to that client

NURSING DOCUMENTATION

2

PRINCIPLES OF EFFECTIVE DOCUMENTATION

ASSESSMENT, NURSING DIAGNOSIS, PLANNING, IMPLEMENTATION

3

FORMS OF RECORDING DATA - are used to communicate current orders, upcoming tests or surgeries, special diets or the use of aids for independent living specific to an individual client;

KARDEX

4

FORMS OF RECORDING DATA - are used to document routine care and observations that are recorded on a regular basis (e.g., activities of daily living, vital signs, intake and output).

FLOW SHEETS, CHECKLIST

5

FORMS OF RECORDING DATA Used to document: • Client's condition, problems, and complaints. • Interventions. • Client's response to interventions. • Achievement of outcomes.

NURSES PROGRESS NOTES

6

METHODS OF DOCUMENTATION - is a problem-oriented approach to documentation whereby the nurse identifies and lists client problems; documentation then follows according problems to the identified

SOAP CHARTING

7

METHODS OF DOCUMENTATION - is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. - Data is recorded in the progress notes, often without an organizing framework. - may stand alone or it may be complemented by other tools, such as flow sheets and checklists.

NARRATIVE CHARTING

8

METHODS OF DOCUMENTATION - method of documentation, in which the nurse identifies a "focus" based on client concerns or behaviors determined during the assessment.

FOCUS CHARTING

HCI

HCI

JHAYS · 5問 · 1年前

HCI

HCI

5問 • 1年前

TERMS

TERMS

JHAYS · 16問 · 1年前

TERMS

TERMS

16問 • 1年前

HEALTH DEF

HEALTH DEF

JHAYS · 5問 · 1年前

HEALTH DEF

HEALTH DEF

5問 • 1年前

ANAPHY PRELIMS REVIEW

ANAPHY PRELIMS REVIEW

JHAYS · 43問 · 1年前

ANAPHY PRELIMS REVIEW

ANAPHY PRELIMS REVIEW

43問 • 1年前

INTEGUMENTARY SYSTEM

INTEGUMENTARY SYSTEM

JHAYS · 75問 · 1年前

INTEGUMENTARY SYSTEM

INTEGUMENTARY SYSTEM

75問 • 1年前

BIOCHEM

BIOCHEM

JHAYS · 27問 · 1年前

BIOCHEM

BIOCHEM

27問 • 1年前

SKELETAL SYSTEM

SKELETAL SYSTEM

JHAYS · 7問 · 1年前

SKELETAL SYSTEM

SKELETAL SYSTEM

7問 • 1年前

joints

joints

JHAYS · 8問 · 1年前

joints

joints

8問 • 1年前

muscle and joint movements

muscle and joint movements

JHAYS · 17問 · 1年前

muscle and joint movements

muscle and joint movements

17問 • 1年前

MUSCULAR SYSTEM

MUSCULAR SYSTEM

JHAYS · 25問 · 1年前

MUSCULAR SYSTEM

MUSCULAR SYSTEM

25問 • 1年前

LIPIDS

LIPIDS

JHAYS · 49問 · 1年前

LIPIDS

LIPIDS

49問 • 1年前

NEUROTRANSMITTER

NEUROTRANSMITTER

JHAYS · 8問 · 1年前

NEUROTRANSMITTER

NEUROTRANSMITTER

8問 • 1年前

NERVOUS

NERVOUS

JHAYS · 100問 · 1年前

NERVOUS

NERVOUS

100問 • 1年前

NERVOUS PART 2

NERVOUS PART 2

JHAYS · 35問 · 1年前

NERVOUS PART 2

NERVOUS PART 2

35問 • 1年前

SPECIAL SENSES

SPECIAL SENSES

JHAYS · 47問 · 1年前

SPECIAL SENSES

SPECIAL SENSES

47問 • 1年前

ENDOCRINE SYSTEM

ENDOCRINE SYSTEM

JHAYS · 41問 · 1年前

ENDOCRINE SYSTEM

ENDOCRINE SYSTEM

41問 • 1年前

問題一覧

1

is any written or electronically generated information about a client that describes the care or service provided to that client

NURSING DOCUMENTATION

2

PRINCIPLES OF EFFECTIVE DOCUMENTATION

ASSESSMENT, NURSING DIAGNOSIS, PLANNING, IMPLEMENTATION

3

FORMS OF RECORDING DATA - are used to communicate current orders, upcoming tests or surgeries, special diets or the use of aids for independent living specific to an individual client;

KARDEX

4

FORMS OF RECORDING DATA - are used to document routine care and observations that are recorded on a regular basis (e.g., activities of daily living, vital signs, intake and output).

FLOW SHEETS, CHECKLIST

5

FORMS OF RECORDING DATA Used to document: • Client's condition, problems, and complaints. • Interventions. • Client's response to interventions. • Achievement of outcomes.

NURSES PROGRESS NOTES

6

METHODS OF DOCUMENTATION - is a problem-oriented approach to documentation whereby the nurse identifies and lists client problems; documentation then follows according problems to the identified

SOAP CHARTING

7

METHODS OF DOCUMENTATION - is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. - Data is recorded in the progress notes, often without an organizing framework. - may stand alone or it may be complemented by other tools, such as flow sheets and checklists.

NARRATIVE CHARTING

8

METHODS OF DOCUMENTATION - method of documentation, in which the nurse identifies a "focus" based on client concerns or behaviors determined during the assessment.

FOCUS CHARTING