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_ _ 
V A process in which people affect one
another through exchange of
information, ideas, and feelings.
V Documentation/Recording is a vital
aspect of nursing practice.
V Include both oral and written
exchange of information between
caregivers.

 _ 
V Verbal Communication
] ses spoken or written words.

V jon--verbal Communication
jon
] ses gestures, facial expression,
posture/gait, body movements, physical
appearance (also body language), eye
contact, tone of voice.
_ 

 _ 
V ð   
- commonly understood words, brevity,
and completeness
V  
- exactly what is meant
V  
  
- appropriate time and consideration of
client¶s interest and concerns
V   
- adjustment ± depending on moods and
behavior
V    
- worthiness of belief
_   _  


v    

V v CUMEj j
] erves as a permanent record of client
information and care.
V 4EP 4j
] takes place when two or more people
share information about client care

jU4 j v CUMEj j j:: the charting


of documents, the professional surveillance
of the patient, the nursing action taken in
the patient¶s behalf, and the patient¶s
programs with regards to illness.
˜

 _ 
  _
§ Communication
2 egal vocumentation
3 4esearch
4 tatistics
5 Education
6 udit and Quality ssurance
7 Planning Client Care
8 4eimbursement
˜    _ v

A. ource Oriented Medical Record


³traditional client record´
hVE B C C MP jEj 
§. Admission sheet
2. Physician¶s order sheet
3. Medical history
4. Nurse¶s notes
5. pecial records and reports
ë. Problem
Problem]]oriented medical record
(POMR)
] arranged according to the source
of information.

h U4 B C C MP jEj 
§. Database
2. Problem list
3. Initial list f orders or care plans
4. Progress notes:
V Nurse¶s notes
‡ (OAPIE)
V Flow sheets
V Discharge notes or referral summaries
]v 
V _oncise method of organizing and
recording data.
V Readily accessible to health care
team.
V eries of Flip cards

V Ensure continuity of care

V Tool for change of shift report

V For planning & communication


purposes.
˜
  ] 

V Personal Data
V ëasic needs
V Allergies
V Diagnostic tests
V Daily Nursing Procedures
V Medications and IV therapy, ëT.
V Treatments like O2, steam
inhalation, suctioning, change of
dressings, mechanical ventilation.
_ 

  
§ B4EV
2 U E h j / PE4MjEjCE
3 CCU4C
4 PP4 P4EjE
5 C MPEEjE & CH4 j   /
4j j / EQUEjCE / Mj
6 U E h jv4v E4Mj  
7 jEv
8 n case of E44 4
 C jhvEj
§ E 4EjE
§§ EBE
§2 v j  use the word ³PEj or ³P in
the chart
§3  H 4 j jE drawn to fill up a
partial line
 ˜ 
§ CHjE
CHjE-- h
h-- Hh 4EP 4 4
Ejv 4 EMEj
]for continuity of care / health care needs.
2 EEPH jE 4EP 4
]provide clear, accurate, & concise
information
]includes: when, who made/was, whom,
what info given/received.
3 EEPH jE 4vE4
] RN¶s duty, must be signed w/in 24 hours.
4 4j hE4 4EP 4
] from one unit to another.
 !    
_"
§ Chart ccurately
2 Chart bjectively
3 Chart Promptly
4 Make jo Mention of an ncident
4eport in the Chart
5 rite egibly and Use nly
tandard bbreviations
"  _" ! 
§. Write Neat and 8. Never _hart Nursing
Legibly _are or Observation
2. se Proper pelling Ahead of Time.
and Grammar 9. _learly Identify _are
3. Write with ëlue or Given by Another
ëlack Ink and se Member of the Health
Military time _are Team.
4. se Authorized § . Don¶t Leave Any ëlank
Abbreviations paces on _hart
5. Transcribe Orders Forms.
_arefully §§. _orrectly Identify Late
6. Document Entries.
_omplete §2. _orrect Mistaken
Information About Entries Properly.
Medication §3. Don¶t ound Tentative
7. _hart Promptly ± ay What You Mean.
  _ 

§. Don¶t Tamper with Medical Records.


2. Don¶t criticize other Health _are
Professionals in the chart.
3. Don¶t Document any _omments that a
patient or family member makes about a
potential lawsuit against a health care
professional or the hospital.
4. Eliminate bias from written descriptions of
the patient.
5. Precisely document any information you
report to the doctor.
6. Document any potentially contributing
patient acts.
"#  v 
$$_ 

§. Refusing to comply with dietary
restrictions.
2. Getting out of bed without asking
help.
3. Ignoring follow]
follow]up appointments at
the clinic, emergency department,
out]]patient or doctor¶s office.
out
4. Leaving against medical advice (AMA)
5. Abusing or refusing to take
medications.
˜ 
 
 
% 

Your notes should contain a
description of what was found and
how you disposed of it.

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ABDELLAH·s
21 Nursing Problems:
1. To promote good hygiene and physical comfort.
2. To promote optimal activity, exercise, rest and
sleep.
3. To promote safety through the prevention of
accident, injury, or other trauma and through the
prevention of the spread of infection.
4. To maintain good body mechanics and prevent and
correct deformities.
5. To facilitate the maintenance of a supply of oxygen
to all body cells.
6. To facilitate the maintenance of nutrition of all
body cells.
7. To facilitate the maintenance of eliminations.
m. To facilitate the maintenance of
food and electrolyte balance.
9. To recognize the physiological responses of the
body to disease conditions . pathological,
physiological, and compensatory.
10. To facilitate the maintenance of regulatory
mechanisms and functions.
11. To facilitate the maintenance of sensory
functions.
12. To identify and accept the positive and
negative expressions, feelings, and reactions.
13. To identify and accept the inter-relatedness
of emotions and organic illness.
14. To facilitate the maintenance of effective
verbal and non-verbal communication.
15. To promote the development of productive
interpersonal relationships.
16. To facilitate progress toward achievement of
personal spiritual goals.
17. To create/or maintain a therapeutic
environment.
1m. To facilitate awareness of self as an
individual with varying physical, emotional, and
developing needs.
19. To accept the optimum goals in the light of
physical and emotional limitations.
20. To use community resources as an aide in
resolving problems arising from illness.
21. To understand the role of social problems
as influencing factors in the cause of illness.
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- describes client·s perceived pattern of
health and well being and how health is
managed.
- # ,  
- describes pattern of food and fluid
consumption relative to metabolic need and
pattern indicators of local nutrient supply.
. *  
- describes pattern of excretory function
(bowel, bladder, and skin)
Ë '/, *

- describes pattern of exercise, activity,
leisure, and recreation.
0 ! ,  
- describes sensory, perceptual, and cognitive
pattern
1  , "

- describes patterns of sleep, rest, and
relaxation.
2    ,   
describes self-concept and
perceptions of self (body comfory,
image, feeling state)
m " , "
 
- describes pattern of role engagements
and relationships.
3 /, "  
- describes client·s pattern of satisfaction and
dissatisfaction with sexuality pattern,
describes reproductive patterns.
+4  !, 

%  
- describes general coping patterns and
effectiveness of the pattern in terms of
stress tolerance.
++5, 6
- describes pattern of values and
beliefs, including spiritual and /or goals
that guide choices or decisions.
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