DocumentationTelana FairchildNurse Practitioner StudentsUMass - Worcester, Graduate School of NursingN/NG 603B

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• Narrative• Focused• Flow-sheet• By exception• Problem oriented

Types of Documentation

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• 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

Problem Oriented

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• 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

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.pdfScott, 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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